Class # 10: "Workers Compensation"
Workers' compensation is a form of insurance providing wage replacement and medical benefits to employees injured during employment in exchange for mandatory relinquishment of the employee's right to sue their employer for the tort of negligence. The trade-off between assured, limited coverage and lack of recourse outside the worker compensation system is known as "the compensation bargain". One of the problems that the compensation bargain solved is the problem of employers becoming insolvent because of high damage awards. The system of collective liability was created to prevent that, and thus to ensure security of compensation to the workers. Individual immunity is the necessary corollary to collective liability.
If you become sick or injured on the job, you can get workers' comp benefits that pay for medical expenses. Covered expenses include emergency room care, doctors' visits, hospital stays, imaging studies (xrays), blood tests, the cost of rehabilitation treatment, and sometimes transportation costs to and from appointments. Each state has different regulations and guidelines for the approval of medical expenses related to a workers’ compensation claim. Generally, medical treatment recommended by your doctor that is proper and necessary to treat your industrially related condition will be covered.
Coverage of Diagnostic Tests:
Diagnostic studies, such as X-rays and MRIs, are usually covered if they are necessary for a doctor to be able to evaluate your industrially related condition.
Coverage of Alternative Treatments
Western medicine and standard treatment practices are most likely to be covered under the workers’ compensation system. Alternative treatments, such as acupuncture, biofeedback, and naturopathic medicine are not likely to be covered. Similarly, experimental drugs and treatment modalities will likely be denied. This certainly does not mean that you are not allowed to undergo these treatments if you are willing and able to pay for the treatments yourself. You can also try to get your worker's comp carrier to cover them, but don't be surprised if the insurance company denies payment on these expenses.
Limitations on the Number of Treatments
Most states have adopted certain statutory limits for various forms of treatment that commonly require multiple sessions. Physical therapy, chiropractic treatment, and massage therapy are common types of treatment that have limited numbers of approved sessions.
In many states, the workers’ compensation system will pay for additional treatment sessions if you have a recommendation from a physician that additional treatment would be beneficial. The claims representative at the insurance company can authorize more treatment sessions.
Sometimes your employer will request an independent medical examination to assess whether additional treatment is likely to improve your condition. Although this seems unfair, you should attend the independent examination; failure to attend in many states can allow your workers’ compensations benefits to be suspended.
Please view the videos below:
Optional reading assignment:
Understanding Health Insurance, by Green and Rowell. 10th Edition)
Read "Introduction" page 556
Read and study "CMS-1500 claim instructions for Workers Compensation" pages 569-571.