The insurance company must pay for medical care, medicines, and supplies that are reasonable and necessary to treat your work injury. This may include doctor visits, hospital care, physical therapy, chiropractic treatment, medication, or counseling.
You have the right to choose your own doctor after the initial visit.
The insurance company cannot refuse to pay for a medical treatment simply because you are at “medical end result” or “maximum medical improvement.” It must continue to pay all medical bills for the rest of your life (as long as the treatment is related to the injury and is reasonable and necessary). After you reach medical end point, the insurance company must continue to pay for “palliative care,” which is medical treatment that helps you remain functional and decreases pain. Examples of palliative care are medications, chiropractic care, acupuncture, physical therapy, massage, etc.
If the insurance company is denying a particular bill, it must file a Form 2 Denial with the Department of Labor. If it does not file the Form 2 within 30 days of receiving the bill, it must pay it. The insurance company can also deny payment for a particular injury or treatment by filing a Form 27. Both the Form 2 and Form 27 must be filed with medical evidence (a doctor's report) supporting the reason for the denial.
In order to fight the insurance company, if they are refusing to pay for treatment, you will need to get a note from your doctor stating that the treatment is "reasonable and necessary" and "related to the work injury."
Medical Bills Not Paid
What do I do if my workers comp medical bills are not being paid?
If your entire workmans comp claim has been denied, the insurance company will not pay any benefits, including medical bills. You need to file an appeal of the denial of your claim (fill out the bottom of the Form 2 denial form) and request a hearing with the Department of Labor. In the meantime, if you have other health insurance, including private health insurance, Medicare, or Medicaid, the other health insurance will pay the medical bills. If you receive a bill from a medical provider or a collection letter, you need to contact the medical provider to tell them to bill your other health insurance. You will also need to send to your health insurance a copy of the denial of your worker's compensation claim.
What if the workmans comp insurance company refuses to pay a specific medical bill?
If the insurance company has accepted your claim but refuses to pay a particular medical bill, you need to appeal the denial of the medical bill and request a hearing with the Department of Labor. The workers comp insurance company only has to pay medical bills that are “reasonable and necessary” and “related to the work injury.” If the insurance company has an opinion from a doctor that treatment is not “reasonable and necessary” or that it is for some other condition not related to the work injury, it can refuse to pay, but it must send to you and file with the VT Dept of Labor a “Form 2 Denial.”
You should appeal this denial and include documentation from your treating doctor supporting your position. You should then contact the medical provider and have them bill your private health insurance, or Medicare or Medicaid, if you have it. You will probably have to send your health insurance company a copy of the denial of the bill from workman's comp insurance.
If you receive a bill from a medical provider or from a collection agency, first you should call the provider and make sure it tried to bill the workman’s comp insurance company first. If the medical provider did try to bill the insurance company but the bill still hasn’t been paid, you must send a copy of the bill to the workers comp insurance company with a letter telling it to pay the bill. It is helpful if you also send a copy of the doctor’s note from the visit with the bill. Always keep a copy of anything you send to the insurance company. If this does not work, send a copy of the bill (and again it is best to also send the doctor’s note) to the VT Department of Labor and ask for an order that the bill be paid.
Please note when your medical bills are paid by private health insurance, Medicaid or Medicare. If you eventually win in your appeal of the denial of your workers compensation claim, or you settle your claim, you will have to pay back the private health insurer, Medicare or Medicaid if it paid any of the medical bills.
Pre-Approval for Medical Care
Medical providers will often refuse to schedule an appointment or go ahead with a treatment until they get “pre-approval” or “preauthorization” from the worker's compensation insurance company.
Under Workers Compensation Rule 7, worker's compensation insurance must respond within 14 days to the request for preauthorization from a doctor's office if the request is accompanied by medical evidence supporting the requested treatment. The workers compensation insurance company has several options, it can:
(1) authorize the treatment;
(2) deny the treatment because the worker's compensation claim was denied
(3) deny the treatment if the preponderance of evidence shows it is unreasonable or unnecessary;
(4) schedule an IME for the Claimant and made a decision on the request for preauthorization within 45 days.
If the workers compensation insurance company does not respond to the request for preauthorization within 14 days, the Claimant or health provider may request an Order from the Department of Labor authorizing treatment. If the insurance company denies the preauthorization request, the Claimant can request an Order from the Department of Labor by providing evidence that the treatment is reasonable, necessary and related to the work injury.