Does Workers Compensation Insurance Have to Pay for a Second Opinion?
Updated: Jun 17, 2019
Medical second opinions are routinely paid for by health insurance. I often get asked if Vermont workers compensation insurance will pay for a second opinion like health insurance does. The answer is yes, workers comp insurance should pay for the second opinion, as long as it is reasonable and necessary.
What does Vermont Workers Comp Insurance Pay for?
Workers compensation insurance is obligated to pay for treatment that is reasonable, necessary, and related to the work injury. Generally speaking, this means that if a treating physician recommends treatment, and that treatment is expected to improve the condition, the workers compensation insurance company will pay for it.
When it comes to seeking a second opinion, there is nothing in workers compensation law that specifically says that it must be covered. However, that doesn’t mean that workers comp won’t cover the second opinion in any case; it just means you need to go about seeking it in the right way.
I recommend to my clients that if they want a second opinion, they should get a written referral from one of their treating physicians. For example, if a surgeon recommends surgery, and you want a second opinion, you should ask for a written referral for a second opinion from that surgeon. Or you can ask your primary care physician for a referral for the second opinion.
How I Helped Clients with Workers' Comp
Here are some specific examples of where I have helped patients get workers’ comp insurance to pay for a 2nd opinion:
Example 1: My client Shannon had surgery on her neck, which did not heal correctly, and the surgeon wanted to perform a second surgery. Shannon did not want the same surgeon to do a second surgery. I counseled her to ask her surgeon for a second opinion. Her surgeon then referred her for a second opinion at larger hospital in a different city. The second surgeon also recommended a second surgery and then performed the operation. The workman's comp insurance company paid for both the second opinion and the second surgery with the new doctor.
Example 2: My client Joe had a surgery on his shoulder. It was still really bothering him after the surgery, and his surgeon told him there was nothing more that could be done. I counseled Joe to ask his primary care physician for a second opinion. His primary care physician did refer him to a different hospital and the workers comp insurance paid for it. He was able to enroll in a functional restoration program at the new hospital which was also paid for by the workers compensation insurance company.
Again there is no requirement in workers compensation law that second opinions must be covered by workers comp. However, in most situations, workers comp will pay for a second opinion if the referral is made by another medical provider.
Do you need a second opinion for a work related injury?
Are you concerned that your workers comp insurance won’t cover it? I am happy to help.