Experienced Virginia workers Compensation attorney Doug Landau and his team are frequently asked why an insurance company is not paying medical bills when the treatment is related to the on the job entry, or by direct referral from an authorized doctor, or for reasonable care under the circumstances.
With apologies to the singer MeatLoaf, two out of three is BAD. Doug Landau notes that you have to satisfy “the three Rs.” Put simply, Medical Care must be:
Causally RELATED to the on the job accident, AND
REASONABLE care, AND
by written REFERRAL (except in the case of emergencies).
In Virginia Workers Compensation claims, if a worker does not follow the correct protocol, they will find themselves “penned in” by the rules of the Comp Commission.
So, there are a number of instances under the Virginia Workers Compensation Act where the insurance company and employer will NOT be ordered to pay for treatment, medicine, therapy, home modifications, medical equipment or nursing care.
Example 1: where an injured worker, who is covered under the protection of an AWARD Order, submits bills for treatment at the direction of their authorized treating doctor, but the documentation does not indicate that it is related to the on the job accident, the insurance company will deny payment, and the Virginia Workers Compensation Commission will not order payment. The causal connection must be clear, or the responsibility for payment falls upon the injured worker, their health insurance or potentially other payers.
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Example 2: where a disabled worker gets reasonable care that IS causally related to the workplace incident, but there is NO referral from an authorized treating physician, likewise, the insurance company, third-party administrator (TPA)and employer can all rightfully deny payment, even in life-saving circumstances. This is because, when injured workers go “outside the chain of referral, ” the insurance company is likely not to be ordered to pay by a Virginia Workers Compensation judge. Once the injured worker has chosen, their authorized treating doctor (often from a panel provided by their workplace, or it’s compensation insuror) that physician is the “captain of the ship“ who gets the direct treatment thereafter. It reminds Lawyer Landau of the old saying, “he pays the paper, gets to call the tune!” Furthermore, switching doctors frequently, jumping from physician to physician, and similar conduct, is frowned upon by the judges of the workers compensation system because of the absence of a valid referral chain.
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Example 3: The Worker’s Compensation team at ABRAMS LANDAU have seen other instances where there has been a referral, by the authorized treating physician, for treatment causally related to the on the job injury, but denial comes because the care is “experimental,” outside traditional medicine, and/or not deemed reasonable. There are many kinds of care that we now take for granted that were, not long ago, considered “beyond the pale. “ Examples include: deep brain oxygen stimulation; platelet rich plasma (PRP – which Landau had undergone with great success), and DMX motion studies. In these cases, unless litigated at several levels so as not to make bad case law or set adverse precedent for the insurance industry, either an agreement is reached to settle the case and let the injured worker pay for their experimental or cutting edge care after the compromise order is signed, or a “carve out” for the experimental care and its potential side effects is agreed-upon.
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Injuries from farm animals can seem like a normal risk of the employment at a farm, stables, or other similar facility. However, if care for a horseback riding accident, fall for a tractor, or crush from a cow does not satisfy “the three Rs,” then treatment may not be the responsibility of the employer’s workers compensation insurance company.
Recently, a client who was involved in an on the job accident asked if mental healthcare would be covered by the insurance company after this worker was crushed by a horse in the course and scope of their employment. The short answer is “not likely,” as the mental health care was not originally “by referral” from an authorized treating doctor. It would likely be challenged as not “reasonable” under the circumstances. It would also be denied as not “causally related” from the original workplace event and orthopedic injuries. So, while the injured worker and their family view this care as necessary to the recovery and reasonable under the circumstances, evidence tends to suggest that the Virginia Workers Compensation Commission would not issue an Order for the insurance company or the employer to have to pay.
Additionally, there’s a question of what happens if and when a Worker’s Compensation claim settles. Normally, the insurance company wants ALL medical benefits ending as of the date of the judge signs the Order signifying approval of the settlement paperwork. The insurance companies almost uniformly also want separation from employment, so that they don’t have to worry about additional claims from the same employee, perhaps even to the same, or overlapping body parts.
In those instances, where a compromise settlement is achieved, with medical care ending when the judge signs off, and separation is. also a term, the settlement funds should be divided into several groups, with one specifically set aside for future Medical Care needs. If the case is settled under a “denied basis“ then health insurance and/or federal, state &/or local assistance programs may be able to pay the bills. If the compromise does not involve such issues, the injured worker should seek to set aside money and instruct their healthcare providers to bill pursuant to the Virginia Workers Compensation Medical Fee Schedule, so that the money goes further. All settlements are estimates of what future indemnity exposure and medical costs will be. Thus, in some cases, the amount set aside for Medical Care will be much more than what is needed, or maybe less, after a number of years, post settlement. That is why Doug Landau advises his clients to consider a Medical Set Aside or “Medical IRA” to safeguard their monies netted from a workers compensation settlement.
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One thing that young clients often overlook is the fact that as time passes from the date of the original, compensable injury, the likelihood of a workers comp insurance company paying for treatment wanes. Just like as the light from a flashlight gets less intense the further you move from the bulb, the question of causal a relationship in the eyes of the insurance companies and third-party administrators, likewise, fades, such that they are more apt to challenge and litigate request for Medical Care 3, 7 and 10 or more years after an on the job accident.
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Experienced Herndon Virginia workers compensation attorney Doug Landau has seen many cases go down a “bad path” where the insurance company has gotten the better of well-meaning family members who are themselves lawyers, doctors, nurses, vocational experts and even judges. That is why consulting with a top workers comp lawyer EARLY in the proceedings can avoid a lot of heartache, delays and getting stuck with bills.
It is for these reasons that an experienced workers compensation lawyer should be consulted as soon as possible. Even in those cases where family members are insurance adjusters, nurses, vocational specialists, and even doctors, the Landau Law Shop has seen cases go “off the rails “where the injured worker and their family have been taking advantage of by adjusters, claims managers, nurse case managers and vocational rehabilitation vendors. Don’t let that happen to you, but instead consult an experienced workers compensation lawyer who actually tries these kinds of cases on a regular basis.
If you or someone you know or care for has recently been permanently injured as the result of an accident on the job, while caring for animals, competing in an athletic event or while working off site, and there are questions about what laws apply, e-mail or call us at ABRAMS LANDAU, Ltd. (703-796-9555) at once.
