If a worker’s compensation claim gets denied, the injured worker can use group or personal health insurance to cover the necessary medical treatment. While health insurance companies are generally not mandated to cover workplace injuries, the law requires them to pay the medical bills in the event of worker’s comp denial. This requirement enables the injured worker to obtain necessary medical treatment promptly. Medicaid and Medicare are other options people injured at work can use to cover medical bills when workers’ comp denies their claims.
In Illinois, workers’ compensation is liable for covering 100% of all the reasonable and necessary medical bills incurred by a worker injured on the job. The injured worker is not liable for any co-payment. The law bars medical providers from “balance billing” patients injured at work. Balance billing is a prohibited practice that happens when medical providers send a patient a bill for the difference between what the insurer pays them and what they usually charge a patient with no insurance coverage. Workers’ comp insurers sometimes act contrary to the law by covering work-related medical costs partially or denying coverage altogether.
Covering Medical Bills After Workers’ Compensation Issues a Denial
Using Group or Personal Health Insurance
If workers’ comp insurance issues a denial, the injured worker can pay the medical bills with his or her group or personal health insurance or spouse’s group health insurance. Most group health insurers will accept to cover disputed medical expenses when the insured or insured’s dependent has an unresolved workers’ compensation case.
The injured worker may have to file a formal document known as a “Notice of Dispute.” The worker may also need to agree to pay back the health insurance upon receiving a settlement from the workers’ comp insurance and sign a reimbursement agreement.
A workers’ comp lawyer can negotiate with the group health insurance so that the plaintiff reimburses the least possible amount. That leaves the injured employee with more cash to use on the road to recovery. The group health insurance may, for instance, take a few pennies for every dollar the worker receives from workers’ comp insurance.
Using Medicaid Coverage
Some employees may not have the group health insurance coverage to cater to the medical bills when Workers’ comp issues a denial. In Illinois, these uninsured workers injured at the workplace have a reprieve. They can use Medicaid coverage to settle their medical bills by proving they are from a low-income bracket or have limited assets.
Medicaid offers some financial protection, as the program covers many medical care costs. The program has some disadvantages, however. The program pays low rates, subjecting beneficiaries to lower quality treatment.
Another disadvantage is that only a few hospitals and medical providers accept Medicaid. The time spent looking for a medical provider that accepts Medicaid may exacerbate the worker’s existing complications and injuries, leading to a permanent disability.
If health insurance or Medicaid is unavailable, the injured worker can turn to Medicare. This federal insurance program is for individuals aged 65 or more and some young individuals with disabilities. The injured worker must get Social Security disability benefits approval to qualify for Medicare.
Before Medicare becomes available, the injured worker will have to wait for 29 months after the disability date. Unlike Medicaid, more hospitals and medical providers accept Medicare. When workers’ comp is delayed or denied, eligible injured workers may turn to Medicare to cover their medical bills.
Why Should an injured Worker Use Health Insurance as a Last Resort?
The injured worker should always insist on filing a workers’ compensation claim. Some employers evade liability by duping injured workers into using their personal or group health insurance for treatment. Doing this shifts medical bills to parties who are not liable for the worker’s work injury. It may also disqualify the worker from future compensation from the employer’s workers’ comp insurer.
What Happens When an Employee Suffers Serious Workplace Injuries?
The common types of work injuries that workers frequently seek compensation for include getting struck by an object, slip and fall injuries, and repetitive stress injuries. Some injuries are so severe that the victim cannot continue living normally. If an employee injured on the job cannot continue working and earning, the employee may be eligible for Workers’ comp wage loss benefits to cover the lost wages.
The injured employee can either receive a one-time lump sum settlement or ongoing weekly wages to help offset any arising expenses while out of work. Some injured employees choose not to file a claim with the workers’ compensation insurance. These victims are content with their health insurance paying the medical bills. If the injured worker opts to forego workers’ comp insurance benefits, the worker might lose any rights to future claims against the employer and the workers’ compensation.
Why Would Workers’ Comp Deny A Claim?
A workers’ comp claim may be denied if:
- The injuries do not relate to the assigned work
- The injuries are preexisting
- The injuries did not require medical treatment
- The injuries did not impede the worker’s earning capabilities
- The claim report failed to provide sufficient information about the injuries
- The injured worker was not a beneficiary in the employer’s policy
What are Non-Compensable Injuries?
Not all workplace injuries are compensable under the law. The workers’ comp insurance company might argue that the worker was not clocked in at the time of injury. The insurer might also argue that the victim was engaging in personal affairs. The workers’ comp insurance may also deny compensation if the injured employee got hurt due to his or her recklessness.
Workers’ comp might issue a denial if the reported employee injuries arose when the employee was committing a crime. It may also deny a claim if the injuries were self-inflicted or the injuries did not get reported on time. The employer and the worker’s compensation insurance company may also deny a claim if there are no witnesses to the worker’s injury.
How Long Do Workplace Injury Cases Take?
Most work injury cases drag on for years before the verdict is delivered. By the time the case resolves, the victim could have spent a fortune on medical treatment. These costs could drive the victim to bankruptcy. For these reasons, workers injured on the job should pursue workers’ comp benefits as soon as possible. The injured workers should also involve a workers’ comp attorney from the onset.
What are the Limitations of Workers’ Comp Insurance Benefits?
In Illinois, the workers’ compensation system gets exempted from liability for the pain and suffering of employees injured at work. Worker’s comp insurance is not accountable for adverse emotions resulting from the pain and suffering, such as humiliation, sadness, anger, frustration, or any other outcome that decreases the victim’s ability to enjoy a quality life, following the incident.
The worker injured at the workplace can pursue compensation for these issues by filing a personal injury lawsuit, not through worker’s comp. To qualify for both workers’ comp and personal injury settlement, another party other than the employer must have caused the workplace accident that caused the employee’s injuries.
How Can an Attorney Help When Workers’ Comp is Denied?
A workers’ comp attorney can help an injured worker whose claim has been denied understand his or her rights and options. The attorney can walk the worker through the process of filing an appeal and pursuing the benefits.
An attorney who understands Illinois workers’ compensation laws can assemble documentary evidence, records, and witness testimony to negotiate a reasonable settlement for the injured employee. The attorney can also represent the injured worker at the official hearing. With the legal support and representation of an aggressive Illinois workers’ comp attorney, the injured worker will have a higher chance of getting a favorable outcome.