Does Workers’ Compensation Cover Medical Care From Specialized Doctors?

Under New York’s workers’ compensation laws, employers are required to provide necessary medical care directly related to the work injury, work illness and the recovery from the work disability. If “specialized” doctors are required for this treatment, then the insurer or employer must pay for the specialized doctors.

When a treating doctor thinks that special treatment, like specialist consultations, surgical procedures or physiotherapeutic procedures, are necessary, the doctor has to contact the insurer for pre-authorization if the treatment costs more than $1,000.

Treatment can proceed without the insurer’s authorization if the insurer doesn’t respond to the request within 30 days. Doctor’s are also obligated to look out for the medical welfare of their patients and can authorize treatment if it’s immediately necessary for medical reasons.

In 2010 the WCB adopted a new set of “Medical Treatment Guidelines” for specific body parts:

  • Neck
  • Back
  • Shoulder
  • Knee
  • And more to be added in the future

As long as your doctor follows these guidelines then there are many avenues of treatment that are deemed ‘pre-authorized’ even if they are more expensive then $1000.00.

But insurers are able to require patients use certain networks for diagnostic tests, like X-rays, MRIs and other radiological testing. The network should be mentioned in the insurer’s statement of rights that workers receive after the injury. Workers need to inform the treating doctor of the network so he or she knows to comply with the insurer’s request.

When does workers compensation stop treating an injury?

Workers’ compensation treats a work injury forever via medical benefits. The worker’s doctor will eventually diagnose him or her as having reached maximum medical improvement (MMI), meaning the worker has recovered from the injury to the greatest extent possible and no further improvement in the condition is expected with continuing treatment.

After reaching MMI, the insurer pays for ongoing medical treatment that is “reasonable and necessary” for the injury. Prescription drugs, regular monitoring appointments and other treatment that prevents the injury from getting worse all count as necessary treatments for the injury. New York also places no caps on medical treatment in workers’ compensation, so the treatment can continue as long as necessary.

What medical treatment does workers’ compensation not cover?

Treatment that is neither reasonable nor necessary is not covered by workers’ compensation. Disputes between workers and insurers often arise because of a disagreement of whether a treatment is helpful and/or necessary.

For example, often workers may wish to visit physical therapists, chiropractors and acupuncturists after the injury. An insurer might believe that these treatments don’t actually improve the patient’s condition or that the patient’s condition cannot be improved no matter how much therapy they receive.

Often these disputes result in hearings in front of the WCB to determine if a treatment does improve a worker’s health. Your doctor is important to testify regarding the necessity and effectiveness of these treatments to improve your condition.

What is the rehabilitation program under workers’ compensation?

The WCB runs a rehabilitation treatment program that is mandatory for workers with a scheduled loss of 50 percent or greater, but open to everyone. Rehabilitation treatment is designed to reduce the worker’s disability to the point where he or she can return to light work, eliminate the disability and live at his or her highest capability. Physical therapy, vocational counseling and other services may help the worker reach these goals.

The law firm Markhoff & Mittman helps New York workers injured at work and pursuing benefits under the workman’s comp system. Contact our office at 866-205-2415 or fill out our contact form.

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