Friday, December 10, 2010

Using Health Insurance to Treat Lifelong At-Work Injuries

Wade Coye, workers' compensation attorney
Work-related injuries can affect a person for the rest of his or her life. If an employee is hurt at work while going through their daily routine on the job, they may qualify to have their treatment, lost wages, and other benefits paid by their employer's workers' compensation insurance carrier. As an employee goes through treatment, the work comp benefits go directly to their doctor's office to pay for their care.

Workers compensation is a type of insurance: it pays benefits to people who qualify under the terms of a policy. It is similar to health insurance, which some employees may have under a private plan or as a benefit to employment. If you qualify for benefits from both insurance policies because of an on-the-job injury, you have a choice to make. Sometimes the choice is made for you with little regard to the consequences.

Many times, the doctor authorized by workers compensation won't be the same one that you get through your health insurance. Because they are different doctors, they may have different opinions. The doctor covered by your health insurance may put you at a high impairment rating, but it doesn't matter for the purposes of workers' compensation if that doctor is not authorized by them. You may be able to get more benefits, including lost wages, if you choose to get treatment through workers' compensation. Many times, we advise clients to not use their health insurance when they are treating for an on-the-job injury. Moreover, your health insurance carrier may deny payment for your claim (and doctor's bills) if your treatment is from a work related injury.

Like most legal cases, workers compensation cases can reach settlement. Once your attorney determines the available benefits, negotiates the terms, and drafts settlement documents, you can choose to settle your case by signing a release. So when does settlement come into the picture? Most of the time, it's when you reach maximum medical improvement, or MMI. When your doctor places you at maximum medical improvement, your condition isn't expected to improve any time soon. MMI is different for each person; one worker may be completely healed while another may have to deal with the effects of their injury for months or years after they first appeared. If your injury requires ongoing treatment, it could be factored into your settlement. Based on the anticipated duration of treatment and the estimated cost, you may get a lump sum. If your treatment is only expected to last a few years, you could get a Medicare set-aside that pays for your treatment in a structured way.

Once you reach settlement, you are effectively releasing your employer from liability, so you are responsible for getting needed treatment and paying for it. This is the point where you may be able to use health insurance. There's been a lot of talk in the health insurance debate about pre-existing conditions. A pre-existing condition is an injury that occurred or an illness that began before the health insurance plan went into effect. They were a hot topic because a lot of health insurance carriers would deny coverage based on the determination that an injury, illness, or condition was pre-existing. If you had private or group health insurance before your at-work injury, you may be able to get your continued treatment covered after your settlement.

But if you buy into a new health insurance plan while you're treating your at-work injury, you might have to fight to get benefits for treatment following your settlement. Because you were hurt before you had the health insurance plan, this is when the insurance company can call the injury pre-existing and refuse or reduce benefits. It depends on whether you are a part of a group plan or you bought a private plan.

If you sign up for a group plan after your at-work injury, you can't be denied benefits for a pre-existing condition. But if you go for a private plan, they can deny coverage based on the fact that your injury happened before you were insured. In any of these cases, it doesn't hurt to speak with a representative from the insurance company you are considering and disclose the details of your condition before you buy the policy. They may be able to tell you if your future medical treatment will be covered.

Insurance policies can be written in confusing language to make consumers think they are protected when they are in fact left vulnerable to loopholes and double-speak. If you're hurt at work, make sure you're getting all the benefits you need and are entitled to. If you need help paying for continued treatment following settlement of the work comp claim, understand your insurance policy. An attorney can help you understand your rights and options when it comes to the lifelong effects of a workplace injury. Don't wait until it's too late for you to get proper treatment and compensation for the time you miss from work. Call a lawyer who understands insurance claims and how they factor into workers' compensation.