Many times a claimant will call and advise that their medical benefits are not being delivered timely. Physical therapy has been denied, a needed surgery is not authorized, or even a simple MRI is disallowed. Here are the top seven reasons why your medical benefits may be interrupted.
1. Poor Communication. Many times medical care is denied because the parties are failing to communicate. Adjusters are responsible for reading all the information on your claim, often more claims than hours in the day. Administrative personnel in health care offices can be overwhelmed as well. Communicate regularly with your adjuster and medical providers to avoid confusion regarding your injury and medical needs.
2. Lack of information. Always confirm that all medical records documenting your work-related injuries, diagnosis, treatment plan, and ability to return to work are being timely delivered to your adjuster. Insurance companies routinely deny workers compensation claims based on “lack of medical documentation.” Ensure your medical providers have a system in place and correct contact information for the adjuster handling your claim.
3. Inadequate documentation. If the providers you are seeing do not routinely handle claims for workers compensation benefits, the necessary opinions may be absent from your records. Consult with your providers and determine whether they are familiar with your worker’s compensation system, the forms used, and the rendering of opinions necessary for the resolution of any questions your adjuster may have regarding your on-the-job injury.
4. Unnecessary procedures. The adjuster is responsible for paying medical benefits which will cure or relieve the effects of your injuries. Determining what medical care is reasonably necessary for your injuries is most often based on specific guidelines set forth in your worker’s compensation laws. A competent lawyer can assist you with your labor issues. These guidelines usually anticipate certain order to the delivery of medical services to provide the least amount of medical care which places you on the speediest road to recovery.
5. Relationship to the accepted injuries. Insurance companies initiate a claim by identifying the current physical harm and setting expected reserves for the medical care costs historically necessary for recovery. Unfortunately, not all the physical harm to your body may be determined by a single test. Medicine is a process, and if an insurance company has not recognized a body part as included in your claim, you may suffer significant delays in the delivery of medical benefits until the issue is resolved.
6. Pre-existing conditions. Despite strides in eliminating the idea of pre-existing medical conditions from our health insurance system, the question still pervades workers compensation claims. The nature and length of time since your prior injury or natural condition will affect the quality and duration of medical benefits you may receive.
7. Personal issues. After an injury at work, life continues. Many family obligations can interfere with our ability to attend all necessary medical appointments. Failure to make advance planning for these activities of daily living can result in an assertion that you have abandoned your medical care.