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Handling the denial of medical benefits through workers’ comp

On Behalf of | Dec 28, 2023 | Workplace Injuries

Most injured workers in Ohio are eligible for workers’ compensation benefits if their harm is work-related. If workers report the matter to their employers and follow the right procedures, they can request disability benefits to replace lost wages and medical coverage. Workers’ compensation benefits can help those with job-related health challenges obtain treatment and pay their bills until they can return to work. Most employers in Ohio carry special insurance coverage or self-insure. The benefits claims process should not be an adversarial one.

Occasionally, workers face challenges during the claims process. For example, may have a valid, approved claim. They may start receiving medical treatment, only to then have payment for treatment already rendered denied. What happens when a worker should receive medical coverage but ends up receiving bills from care providers instead?

Workers have appeal rights

Sometimes, determinations related to workers’ compensation claims are inappropriate given the circumstances. Employees may need to appeal those unfavorable determinations. Typically, workers have the right to initiate an appeal about an unfavorable decision regarding their claim within 14 days of that determination.

However, an issue with medical payments during an approved claim may have a slightly different timeline. Such issues are common when companies self-ensure, as they may want to avoid the costs associated with paying for medical care. Workers may not know immediately that there was an issue with payment for their treatment. It may only be when bills start arriving addressed to them that they recognize what has happened.

The injured worker can potentially ask for a review of the situation. Sometimes, there may not have been adequate documentation connecting their injury to work or affirming the necessity of certain treatment. Workers’ compensation insurance often might follow through with payments if applicants follow the right procedure. The worker typically needs to provide information about their claim and possibly also information validating the necessity of the specific treatment they underwent.

The process of getting medical coverage after a denial of payment can be frustrating and complex. Many workers need help from an attorney familiar with Ohio workers’ compensation laws. As such, realizing that denied medical payments are not the end of the process but the beginning of another process may benefit those recovering from a job-acquired medical condition.