Medical bills are every American’s worst nightmare. Thousands of dollars in bills and especially for no fault of your own in your workplace, would be dreadful. While workers’ compensation is your fallback plan, what happens to medical bills when workers’ comp is denied?
When workers’ compensation claims are denied, injured employees often find themselves grappling with unexpected financial burdens. Medical bills, in particular, can be overwhelming, leaving individuals and their families in precarious situations. Did you know that in California, approximately 20% of workers’ compensation claims are denied? It means that a significant number of workers must seek alternative ways to manage their medical expenses. Understanding the reasons behind the denial and exploring alternative avenues for managing these expenses is crucial. Let’s delve into the complexities of what happens to medical bills when workers’ comp is denied and discover potential solutions for this challenging landscape.
Why was your workers’ comp claim denied?
If you are wondering, does workers’ comp cover medical bills – it does. Workers’ compensation is the fallback option for all employees and a mandatory requirement for all employers under California law. For all workers that experience workplace injury that impedes their ability to work, worker’s compensation helps to provide financial assistance during such situations.
Like all claims, workers’ comp does pose the danger of getting denied as well. There are several reasons for that. These are listed below:
Compensability: The most common reason why most workers’ comp claims are denied in California is because they are not compensable as the injury did not occur at the workplace. That’s the first rule of the Workers’ compensation – that the worker’s injury should be occurring in the workplace or within the premises or should be work-related. If it falls outside the scope of your work, or is classified as an illegal act, it will be denied. If you were inebriated or were found to be instigating the injury, the worker’s comp claim will be denied.
Failure to report on time: As per the California law, it is necessary to report the injury that happened in the workplace as soon as possible and within 30 days of the injury. If your employer doesn’t hear from you within 30 days of the injury, you lose your right to claim workers’ compensation. The promptness helps to prevent problems and delays to receive the benefits. You can refer here to learn more about what you need to do to ensure a successful claim filing.
Status of your employment: To receive the benefits of workers’ compensation or even qualify for it, you need to be a full time or a part-time employee of the organization. Often, companies misclassify employees to avoid paying the premium for the workers’ comp plans separately. Only if you are an independent worker or not a direct employee of the company, will you not be eligible for the workers’ comp benefits, and might get your workers’ comp denied.
What to do if they denied workers compensation claims?
Facing a denial for your workers’ compensation claim can be stressful. Like stated above, denial of workers compensation claims can be due to various factors. However, it is important to remember that a denial isn’t the end of the road. There are several steps you can take to appeal the decision and potentially secure the benefits you deserve. Understanding the reasons behind the denial, gathering the necessary documentation, and seeking legal assistance are crucial steps in this process.
Listed below are some of the steps you can take to ensure that your medical bills don’t pile on.
File for an adjustment claim application
If your workers’ comp is denied, you need to file an adjustment claim application with California’s Workers’ Compensation Commission (WCC). This formally registers your claim with the commission directly. It is essential to file this claim within three years after your work-related injury. If you fail to file it within the stipulated timeline, then the rejection decision will be final and will bar you from permanently receiving workers’ comp benefits.
Request a hearing
Post filing the application for the adjustment claim, the commission is likely to assign you a case number for the same. Your case will be assigned an arbitrator to listen to your case and will enable you to move forward to the hearing. It will provide an opportunity to discuss it further with the assigned arbitrator and your employer.
You can request an emergency hearing and get a decision within 180 days. All you have to do is submit a petition for immediate hearing for the denied workers compensation claim. It is best to consult with a lawyer to fast track this process as it can be quite confusing to navigate through.
File an appeal
In case the arbitrator decides to uphold the decision of denied workers compensation claim, you can file a petition for review to appeal this decision. You have to do this within 30 days of receiving the arbitrator’s decision.
Following this, three commissioners from the WCC will hear your appeal, examine the decision received from the arbitrator, and schedule a hearing for the same. You can prepare and submit written arguments to support your claims to the commissioners before the actual hearing takes place. It is essential to note that you will have only five to ten minutes to argue and present your case at the hearing. Thus, it is imperative that you consult a workers’ compensation attorney to be successful with the hearing as they have quite a lot of experience handling similar cases. Note that the decision from the commissioners will be ready within 60 days of the hearing.
Does Workers’ Compensation Fully Cover Medical Expenses?
Usually, workers’ comp covers all medical expenses arising from the treatment for the work-related injury. Under California, workers are entitled to receive $10,000 from their employers for the initial medical expenses. These bills include and are not limited to emergency medical expenses like room care, hospitalization stay, visits to the doctor, diagnostics like X-rays, ECGs, MRIs, blood tests, and more, rehabilitation treatments, and any medications that are prescribed.
As per the Department of Industrial relations in California, California workers’ compensation law requires claims administrators to authorize and pay for medical care that is reasonably required to cure or relieve the effects of the injury. Under laws enacted in 2003 and 2004, this means care that follows scientifically based medical treatment guidelines.
Although, your employer’s insurance can deny certain medical treatments that it might deem unnecessary to your recovery plan, through the utilization review. However, this can be appealed, and an independent review can be requested to challenge the denial request.
Workers comp claim denied now what: Alternative ways to pay for medical bills
If your workers’ comp claim is denied and you are wondering now what? Well, it is time to find alternative ways to pay your bills. While you fight your case and await a decision, there are a few options to explore. The good thing is you don’t have to pay the hefty price out of your own pockets. The following can be some good options to consider.
Group/personal healthcare insurance
Group or personal healthcare are open to covering the medical bills while your case for denied workers compensation claims goes on in the background. In case you are covered by your partners’ health insurance, that will cover your medical bills as well.
However, to do that you need to fill and complete a notice of Dispute form to the insurance company. You might also have to provide your consent and sign a document stating you will pay back the insurance company after receiving the settlement.
Medicaid
While you wait for a decision on your denial of workers compensation claim, Medicaid can be a valuable resource to help cover these medical expenses during this uncertain period. Here’s how Medicaid can be used to pay medical bills while you await a decision from workers’ comp:
Eligibility: First, ensure that you meet the eligibility criteria for Medicaid in your state. Medicaid is a means-tested program, so your income and assets will be considered when determining your eligibility. If you qualify, you can receive coverage for a wide range of medical services.
Coverage: Medicaid can cover a variety of medical expenses, including doctor visits, hospital stays, prescription medications, and more. This can provide significant relief while you wait for your workers’ compensation claim to be processed.
Coordination with Workers’ Comp: If your workers’ compensation claim is eventually approved, Medicaid may seek reimbursement for the medical expenses it covered during the waiting period. This process is known as “coordination of benefits.” It’s important to keep detailed records of all medical treatments and expenses to ensure a smooth transition and reimbursement process.
Medicare
Medicare can be a critical lifeline when dealing with medical expenses for workers comp not paying medical bills. Medicare can help cover a wide range of medical services and treatments, including hospital stays, doctor visits, and prescription medications.
Medicare Part A (hospital insurance) covers inpatient care, skilled nursing facility care, and some home health care services. Medicare Part B (medical insurance) covers outpatient care, preventive services, and some home health care. These coverages ensure that you have access to necessary medical treatments without bearing the full cost out of your pocket.
If your workers’ compensation claim is approved later, Medicare may coordinate benefits and seek reimbursement for the expenses it covered during the waiting period.
Joseph Pluta: Making Workers’ Comp Claims Easy
If your workers comp is not paying medical bills, it is essential to hire the right attorney for it. Navigating workers’ comp, filing claims, preparing for a hearing, amidst recovery can be pretty daunting and stressful. Cut down on the worries and call the experts: Joseph Pluta law firm. They have been dealing with workers’ rights for years and have been successfully fighting compensation claims over the years in California. Let them handle the messy affair while you relax and focus on getting better instead of your medical bills.
Conclusion
Getting your workers’ comp denied can be overwhelming especially with the piling medical bills. However, as illustrated above there are options to help manage these expenses and appeal your case to the Commission. Medicaid and Medicare can provide temporary relief, while you explore your appeal options to potentially secure the benefits you deserve with an experienced lawyer. Remember, a denial isn’t the end of the road; it is just a redirection to the right path on your recovery journey.
FAQs
1. Is there a time limit within which medical billing needs to be completed?
Yes, all medical bills need to be submitted by medical providers within a year of providing the services. Failing to do so might result in denial of workers’ compensation claims.
2. What resources can I leverage for information?
You can go to your local I&A officers for information, and it is free. They will advise you how to act but they are not lawyers. You can refer here for more information.
