Work Injury- Insurance Carrier Denying Medical Bills

Date: January 3, 2015
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Question: I got my fingers caught in a machine at work 3 years ago. I was out of work for about a year and a half and I was paid benefits for that time. I then settled the wage loss case with the understanding that the insurance carrier would continue to pay my medical expenses. I just went to the pharmacy to pick up a prescription to treat the arthritic pain in my hand. The pharmacy told me that the comp carrier is denying payment. Can they do that? Anonymous, Montrose, Pa.

Answer: There are several instances where a carrier can deny payment for the treatment of an accepted work-related injury. One example is if there has been a judicial determination that you have fully and completely recovered. Another instance is where you have resolved all aspects of your claim, medical and wage loss, by way of a Compromise and Release Agreement. The carrier can chose to contest payment of the bills by asserting that the bills are not causally related to your work injury. The carrier can also request a Utilization Review  of the bills which asks that a health care parcticioner be assigned by the Workers Compensation Bureau to assess whether the treatment is reasonable and necessary. Absent those circumstances, the insurance carrier runs the risk of being exposed to penalties if they simply deny a medical bill with no good reason to do so.

If you’ve suffered a work injury and have questions about your claim, contact me at tcummings@dlplaw.com or call (570) 347-1011 for a free consultation.

Disclaimer: The above article is for instructive purposes only and each case is fact sensitive.  Consultation with an attorney should be obtained instead of reliance upon the legal issues discussed in this column. 

Tom Cummings
Thomas P. Cummings has been a Partner with Dougherty Leventhal & Price, LLP since 1996 and has been with the firm since 1991. He focuses his practice on workers’ compensation, Social Security Disability and personal injury cases.