Looking to Alternative Sources When Denied Benefits

Sunday, September 14, 2003 | 0

A recurring theme in the injured worker sections of workcompcentral is that the injured worker is ultimately responsible for him or her self. An example of this truism can be found on almost a daily basis in the workcompcentral Injured Workers Forum.

A recent problem raised by a worker in the Forum (edited for clarity and grammar):

"I have been off of work for about 6 months now because I have heal spurs in both feet which are very painful for me. I have been seen by 5 doctors, been denied PT for the 2nd time and have had 1 cortisone shot in each foot, which they did not work for me. My current Dr. has prescribed PT and orthodics for me, but WC does not feel that it is medically necessary for me. So, I get to sit at home and wait for them to figure out what is medically necessary. Meanwhile they have forced me to get an attorney and fight for medical care. If it weren't for my husband working and being so understanding we would have lost our house. Then I read in the paper how WC complains about how much fraud is involved with WC claim, when I truly feel that the only crook here is the WC denying truly injured workers the care and benefits that they deserve to get back on their feet again!!! "

Indeed, we get asked often why there aren't more stories about insurance company fraud, and while insurance fraud certainly does exist, the definition of fraud would not include a situation per the above because of the legal requirements for fraud. Denial of a claim is not necessarily fraud, nor is the denial of any particular benefit, though the wrongful denial of a claim or a benefit will result in penalties and/or increased awards. And while most feel that penalties are not a deterrence to insurance companies with millions of dollars to spend, in fact they are a deterrence, as any claims examiner subject to an audit will tell you.

Nevertheless, the issue presented in the above post is really what can an injured worker do in a situation where workers' compensation has denied treatment or other benefits, such as temporary disability indemnity? There are alternatives, as suggested by the following reply post:

"I would suggest that if you have access to medical care through group or private insurance you seek all the care that you need in order to be able to return to gainful employment. Group and private insurers must provide benefits if they are denied by your W.C. Carrier. They can then file a lien to seek reimbursement from W.C. IF you have access to other medical insurance - use it!! If you have a medical condition that needs treatment - get it. Let the insurance companies hash out who is liable. Same is true with State Disability Insurance. If you are certified disabled and W.C. won't pay - sign up for SDI and then let the two agencies hash out who is ultimately liable. Bottom Line is that you must take care of yourself through every means available. "