Next steps to take after medical treatment claim is denied in Georgia
Despite stringent occupational health and safety regulations, workplace accidents still happen. An estimated 2.8 million work-related injuries occur in the U.S. every year, according to the Bureau of Labor Statistics.
The good news is that most work-related injuries in Georgia are covered under workers’ compensation laws. The insurance provides compensation for medical expenses and additional compensation for lost wages.
Unfortunately, not all claims are accepted. In particular, medical treatment coverage may be denied for a number of reasons.
If your medical claim has been denied, continue reading—and then reach out to our team at Gerber & Holder Law for assistance.
Reasons why your treatment might be denied
The denial of workers’ comp treatment can be tough to handle. It leaves the injured worker with 2 options: either pay the medical bill out-of-pocket or continue in pain without resolving the issue. Neither of these options may be viable for you.
Here are some common reasons for denial of treatment:
Like most legal matters, workers’ compensation claims must adhere to strict deadlines. In Georgia, an injured worker must report the injury to their supervisor within 30 days. However, the best time to report is immediately or as soon as possible. This makes it easier to review the incident while the evidence is still fresh. Failure to report the injury may be grounds for claim denial.
The other important deadline is the statute of limitations. Under Section 34-9-82(a) of Georgia compensation law, an injured worker has 1 year from the accident date to file their claim with the State Board of Workers’ Compensation.
Failure to meet these deadlines means you forfeit your right to the benefits. However, there are special circumstances when the deadline may be extended or tolled. It’s best to talk to an attorney to determine if these exceptions apply to your case.
Disputes over injury
Insurance companies are notorious for disputing work-related injuries to reduce the cost of medical expenses. There are 2 possible disputes over injuries.
For one, the employer and their insurance carrier might downplay the extent of your injuries and refuse to pay for certain medical treatments that they deem “unnecessary.”
The second scenario is that they may dispute that the injury is not work-related, and therefore, ineligible for compensation.
In both these situations, you will likely need an experienced workers’ comp attorney to help you.
Filing after you’re fired
Although you can legally file for a workers’ compensation claim after leaving your job, it may be difficult to prove that you were injured on the job. The employer may also argue that this is an attempt to get revenge for firing you.
You will need strong medical evidence to prove that your previous job is responsible for your current health problems. However, this should not discourage you from filing. Speak with an attorney for more guidance.
Unauthorized medical provider
Under Georgia compensation laws, your employer should provide a posted panel of physicians. This list should include specialists in different medical fields. In addition to providing treatment, these physicians also provide medical analysis for your injuries and necessary treatment.
Seeking treatment from an unauthorized medical provider may cause problems with your workers’ compensation claim process. For one, your doctor may not accept the payment schedule proposed by the insurance company. It’s important to choose the best doctor from the provided list, which we can help you do.
How to handle denied medical treatment
The last thing you need while nursing your injuries is a denied claim. It could mean delayed recovery and prolonged financial constraints. Fortunately, it is not necessarily the end of the road.
Here are some possible options for resolving your case and securing payment for your medical expenses:
- Call the insurance adjuster. The treating physician can only proceed with treatment after getting authorization from your insurer. Although this is rare, sometimes the problem can be resolved with a simple phone call to clear up an issue—like misplaced paperwork—without much trouble. Even if the adjuster doesn’t help, calling is the fastest way to find out the reason for the denial.
- Request a medical authorization form. Under rule 205(c), the injured worker can request medical treatment authorization by filing a Form WC-PM. This form requests a judge to authorize medical treatment. The workers’ comp judge hears these disputes through a telephone conference. After, the judge can compel the insurance company to authorize treatment. Either party can appeal the decision by requesting a hearing within 20 days.
- Request a hearing. The State Board of Workers’ Compensation usually handles workers’ compensation disputes. You can initiate the process by filing a Form WC-14. All relevant forms are available on the State Board website. After filing, you will receive a notice of hearing, indicating when and where the hearing will occur. As this is a legal matter, you should hire an experienced attorney to argue your case.
- File an appeal. If you don’t agree with the judge’s decision, you can take your appeal to the next level. Workers’ comp appeals are handled by the Appellate Division of the State Board of Workers’ Compensation. Your case will be reviewed and a final decision rendered. Sometimes appeals are heard outside the workers’ compensation system. However, appeals often mean delayed treatment, which is not the ideal scenario.
Insurance companies exist to make money. They are known for frustrating injured workers in an attempt to reduce or deny settlements. A small slip-up can lock you out of the benefits you deserve. Having a skilled workers’ compensation attorney by your side ensures your rights are protected all the way.