What Medical Expenses Will Workers' Comp Pay?

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If you become sick or injured on the job, you can get workers' comp benefits that pay for medical expenses. Covered expenses include emergency room care, doctors' visits, hospital stays, imaging studies (xrays), blood tests, the cost of rehabilitation treatment, and sometimes transportation costs to and from appointments.

Each state has different regulations and guidelines for the approval of medical expenses related to a workers’ compensation claim.  Generally, medical treatment recommended by your doctor that is proper and necessary to treat your industrially related condition will be covered.

Coverage of Diagnostic Tests 

Diagnostic studies, such as X-rays and MRIs, are usually covered if they are necessary for a doctor to be able to evaluate your industrially related condition.

Coverage of Alternative Treatments 

Western medicine and standard treatment practices are most likely to be covered under the workers’ compensation system.  Alternative treatments, such as acupuncture, biofeedback, and naturopathic medicine are not likely to be covered. Similarly, experimental drugs and treatment modalities will likely be denied.

This certainly does not mean that you are not allowed to undergo these treatments if you are willing and able to pay for the treatments yourself. You can also try to get your worker's comp carrier to cover them, but don't be surprised if the insurance company denies payment on these expenses.

Limitations on the Number of Treatments 

Most states have adopted certain statutory limits for various forms of treatment that commonly require multiple sessions. Physical therapy, chiropractic treatment, and massage therapy are common types of treatment that have limited numbers of approved sessions.

In many states, the workers’ compensation system will pay for additional treatment sessions if you have a recommendation from a physician that additional treatment would be beneficial. The claims representative at the insurance company can authorize more treatment sessions.

Sometimes your employer will request an independent medical examination to assess whether additional treatment is likely to improve your condition. Although this seems unfair, you should attend the independent examination; failure to attend in many states can allow your workers’ compensations benefits to be suspended.

Surprising Benefits May Be Covered

States vary widely on how easily and frequently treatments are authorized. In Texas, for example, fewer types of treatment are paid for by the workers’ compensation system than in many other states. On the other side, Washington and Oregon are very liberal in the benefits given to injured workers.

If you are in a state that authorizes treatment liberally, you may be surprised at the types of treatment authorized and paid for by your workers’ compensation benefits. One example: you are injured at work and hurt your back. You subsequently develop unrelated foot pain, causing you to limp. Limping increases your back pain to the point that you now require back surgery. Your back surgery will likely be covered by the workers’ compensation system, and your foot treatment to alleviate your limp may also be covered.

When Will the Bills be Paid?

Once you have an open workers’ compensation claim, your workers' comp insurance company should pay your bills immediately and continue to be paid as you receive treatment, as long as your claim remains open. The insurance company usually requires you to get pre-approval before incurring medical costs, but this is something your doctor or other medical provider should take care of.

How to Start Treatment

Tell your doctor about your workers' comp claim the first time you seek treatment from your doctor for the workplace injury. Your doctor will then know to bill the appropriate insurance or state department for your treatment, or will ask you to file a workers' comp form during the visit so the proper company or department can be billed. However, some doctors do not take workers' comp cases; you may want to ask before you make an appointment.

Your private medical insurance carrier may deny any treatment related to your workplace injury or industrial disease. Therefore, if the workers’ compensation system does not authorize and pay for your treatment, and you wish to proceed with the treatment, you will need to be prepared to pay for the treatment out of your own pocket.

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