Certified Specialist, Workers' Compensation, The State Bar of California
Board of Legal Specialization
YOUR MEDICAL TREATMENT
If you are injured on the job and entitled to Workers’ Compensation benefits, your employer (or its insurance company) is required by law to provide you medical treatment to address the health problems caused by your injury. This treatment does not have maximum dollar limits, nor does it have deductibles or co-payments. It includes all things medically necessary to allow for the best treatment possible including doctor visits, prescriptions, therapy, laboratory testing, and nursing care when required. It may also include durable medical equipment provided to you at no cost, including mobility assistance devices where required. For very serious injuries it may also include home nursing and modifications of your home or vehicle. If hospitalization and/or surgery is necessary for your injury, the cost associated with that will be paid by the insurance company and payment arrangements are made directly in advance between the hospital and the insurance carrier.
Expenses incurred for trips to and from medical treatment (parking and mileage) are reimbursed. You will be asked to keep a careful record of your visits to medical professionals and the round trip mileage.
The insurance company may also be required to treat other health problems you may have if treatment for those problems is medically necessary to allow for treatment for your injury. Common examples are treatment for pre-existing diabetes or provision of a weight loss program in anticipation of surgery.
Should the insurance company be unsure about treatment recommendations of your primary treating physician, the reports will be submitted to Utilization Review for a determination as to whether the treatment falls within guidelines adopted by the Department of Industrial Relations and whether the treatment is reasonable and necessary. If the Utilization Review physician determines that the treatment recommendation is not appropriate, the determination can be submitted for Independent Medical Review for another look. The insurance company is not required to pay for treatment that has not been pre-approved except in extreme emergency situations.
You may be required to select your treating physician from a provider network (called an “MPN”). If there is an MPN, you may change treating doctors within the network whenever you desire, and there is a provision for second and even third opinions regarding treatment from within the network itself should you desire.
Under present law, medical treatment disputes may not normally be heard by a judge. Nor may such disputes be determined by a neutral physician unless the parties agree to be bound by his or her opinion.
Unless you settle your Workers’ Compensation case by Compromise and Release, medical treatment continues to be available, as needed, for your lifetime. The lifetime anticipated cost of medical treatment to cure or relieve from the effects of your injury may far outweigh the value of projected disability payments. For settlements, the value of the medical treatment must be factored into the settlement amount.