What Can I Do If the Workers’ Comp Insurer Denies a Medical Procedure?

It’s frustrating to face a medical treatment denial from a workers’ compensation insurance provider. You need treatment for your workplace injury, but you can’t proceed without financial support from the workers’ comp system.

You thus probably wonder why the insurance carrier rejects your treatment, even if your doctor proves it’s necessary.

You also want to know the best options to appeal the denial and finally receive the compensation you deserve.

So, read on and learn how to deal with a treatment denial from the insurance company. Calling a Burbank workers’ compensation lawyer will also help dispute the decision and prove you need the treatment.

Your Rights to Medical Care After Sustaining Workplace Injuries

You deserve to receive proper medical care after sustaining work-related injuries, including:

1. Emergency Care Treatment

Your employer should authorize urgent medical care if you get injuries from an emergency accident. An example is when you sustain a severe laceration, requiring immediate treatment to close the wound.

You can file the workers’ compensation claim form after receiving emergency care. Submitting this form will start the benefits claim process.

2. Non-Emergency Medical Procedures

You should first file a workers’ comp claim if you sustain injuries from a non-emergency case. An example is noticing progressing back pain because of repetitive stress, and you need treatment to relieve the symptoms.

Your employer’s insurance provider should then authorize health care service within one working day of filing the form.

3. Medical Coverage During the Claim Investigation

After you file a claim, the insurance provider has 90 days to investigate your claim before releasing an approval or denial verdict. You deserve to receive up to $10,000 worth of injury-related health care coverage during this period.

However, the insurance adjuster must approve each service before authorizing it. It’s when they may deny a health care procedure and assert it’s unnecessary.

Why Insurance Providers Deny a Medical Procedure Necessity

As mentioned above, you deserve to receive health care service after sustaining a workplace injury. However, you must pass the Utilization Review (UR) to prove you need a particular procedure. This step is to secure authorization from the insurance provider before getting any service to ensure they will cover the cost.

You should thus present your physician’s report, referral, and prescription to prove you need the service. The problem is that the insurance adjuster may try to prove you don’t need it.

They make such decisions to avoid releasing funds and protect their business interest. They may even completely deny your whole workers’ compensation claim.

Fortunately, you may still appeal their decision through the Independent Medical Review.

Appealing a Medical Service Denial

You and your physician may request an Independent Medical Review (IMR) if the insurance provider denies your treatment. You have 30 days to make this request after receiving the health care service denial.

The Division of Workers’ Compensation (DWC) will select an independent physician to review your case. This physician will determine if the presented health care procedure is necessary for your condition.

You should thus prepare enough evidence when requesting IMR, proving you need the procedure. Work with your primary physician and Burbank workers’ compensation lawyer to compile the necessary documents.

Hire a Workers’ Compensation Attorney in Burbank to Prove the Treatment You Need

It could be frustrating to receive a medical care denial from the insurance company. However, remember that you can still dispute that decision by requesting an IMR and proving your deserved treatment.

Hiring a Burbank workers’ compensation lawyer will help appeal a treatment denial and optimize your entire claim to get your rightful benefits.