Many people call in and tell me that the workers’ compensation insurance company is not paying for all their medical bills. Understandably, this is a very worrisome situation.
If a workers’ compensation claim has been accepted, the law requires that the employer and its workers’ compensation insurance company provide medical treatment and pay the bills for any treatment that is “medically necessary.” That same law, however, gives the employer and its insurance company the right to “direct” any employee’s medical care.
What I have seen happen is that the workers’ compensation carrier will not pay for visits to a doctor that they did not pre-approve. Certainly, the workers compensation carrier is typically liable for any medical bills incurred from EMS and emergency room visits. But outside of these general and necessary bills, my experience has been, you may have to fight for what you want.
Workers’ compensation is responsible for paying for medical visits, diagnostic tests, epidural steroid shots, physical therapy, surgery, and related rehabilitation services that are deemed medically necessary. If, for example, you want them to pay for home care by a relative, that is typically not compensated, unless the relative is a licensed medical provider.
What Is Covered Under NC Workers’ Compensation?
If you have an accepted workers' compensation claim in North Carolina, you are entitled to medical benefits. This usually includes things like doctor's appointments, physical therapy, prescriptions, and even surgery. To put it simply, medical benefits for any treatments that help you recover from your injury.
Compensation can include, in many instances:
- Travel costs to and from medical appointments (if more than 20 miles round-trip)
- Attendant care
- Medical equipment
- Home or vehicle modifications
The workers’ comp insurance company is responsible for 100% of your approved medical expenses, so you are not responsible for co-pays as with regular health insurance.
Who Controls Your Care Under Workers’ Comp?
In North Carolina, your workers’ comp insurance carrier has the right to choose which doctors you see, when you see them, and which treatments you receive. (They may even appoint one of their approved nurses to “watch over” you. Click here for more about who these nurses may really be watching out for.) If you refuse certain treatments, they can (and likely will) discontinue benefits.
If you want a second opinion, you have the right to request it. Be forewarned. The insurance company might deny your request or try to direct which doctor you see before they agree to pay for treatment.
You have the option of requesting to see your own doctor. Based on my experience, however, the insurance company is likely to refuse to pay for that. If your doctor makes any new treatment recommendations, they will probably refuse to pay for those too. If you choose to pay for the treatment on your own, they may not reimburse you.
Delay, Deny, Defend Schemes Do Not Deter Us
As you've probably guessed, these issues can (and usually do) lead to lots of problems for the injured worker who is only trying to heal so they can get back to work and get on with their life. Yet instead of moving on and healing, many of them find themselves wrestling with their insurance company over denied medical treatments.
We’ve seen so much of these denial tactics that we developed a book called Insurance Companies (and Others) Behaving Badly.
I have been a lawyer for more than 25 years and I’d like to be able to say I have seen it all when it comes to insurance company denials. Truth be known, they seem to never stop inventing new reasons to try to deny injured workers. But their denials don’t deter me or any of our other workers’ comp lawyers.
NC Workers’ Compensation Lawyers Offer FREE Case Evaluation
Based on our team’s 150 years of combined experience, it is almost always a good idea to speak with us about your workers’ comp questions and issues. Our confidential case evaluations are free, and you may learn that you’re entitled to more than the insurance company claims.
If workers’ compensation is refusing to pay for any medical treatment, or if they are denying approval of medical treatment, contact us or call 1-866-900-7078 to learn how a workers’ compensation lawyer from the Law Offices of James Scott Farrin could potentially benefit you.