Unpaid Medical Bills and Pennsylvania Workers’ Comp

When you suffer a work-related injury, one of the primary concerns is medical treatment and who will be responsible for payment of medical bills. Depending on the seriousness of the injury, unpaid medical bills can pile up into a significant sum.

The Pennsylvania Workers’ Compensation Act provides for the payment of medical bills. In cases where the insurance carrier accepts the injury, this is normally not a concern. However, when the insurance carrier denies a claim, that is when medical bills pile up or treatment stops due to lack of insurance. In either scenario though, insurance carriers typically cause problems when paying medical bills.

What medical bills are covered by workers’ compensation?

The Act requires the insurance carrier to pay for “reasonable, necessary, and casually related” medical bills. At any point, anyone of those three words can cause medical bills to be denied. It is also important to note that workers’ compensation insurance is NOT regular health insurance. It only covers medical bills related to the work injury, it does not cover non work-related medical conditions, although you may be out of work with no private health insurance coverage.

That being said, workers’ compensation covers doctor visits, physical therapy, surgery, various injections, medical devices, hospitalizations, medications, and more.

What problems arise with payment of medical bills?

The answer is many problems arise. Many cases in litigation have an unpaid medical bill issue going on. The first, and obvious problem that arises I when an injured worker’s claim is denied. When you have a denied claim, the workers’ compensation insurance carrier will not pay medical bills or wage loss benefits to you. You will have to file a Claim Petition and begin litigation to have your claim approved. In this scenario, the injured worker should have medical bills submitted to private health insurance until there is a resolution of the claim. If you have a denied claim and no private health insurance finding medical treatment can be downright frustrating.

Other problems can arise over whether the workers’ compensation insurance carrier believes the treatment is not reasonable, necessary, or related to the work injury. There are a few issues that arise form this scenario. First, the carrier may simply not believe the treatment is necessary. Second, and quite frequent, the treatment is for the injury that has gone beyond what the accepted injury is. By way of an example, the insurance carrier may have accepted a “shoulder contusion” and now it has come to light that the actual injury is a rotator cuff tear that requires surgery. Insurance carriers often deny surgery and post-surgery therapy due to the fact they only accepted a ‘contusion’. These scenarios are frequently litigated by filing a Review Petition to expand the description of injury.

Sometimes the injury is originally thought to be a specific body part and accepted as so, only to find out through treatment it is actually another body part. By way of example, sticking to the shoulder, the insurance carrier may accept a ‘shoulder contusion’ but through treatment it is determined the shoulder pain is actually radiating from the neck and the actual injury is a nbeck injury. Medical bills are then denied because the neck is not an accepted body part. Again, this leads to litigation of a Review Petition to correct the accepted injury.

Insurance carriers also deny medical bills that although are related, they do not appear to be. For instance, you may need surgery for your work injury, but your surgeon is requiring cardiac clearance. Next thing you know, the cardiologist medical bills I denied based upon the carrier saying it not related to the work injury.

Can the insurance carrier deny medical bills when I have an accepted claim?

Besides a few of the scenarios discussed, generally, the insurance carrier cannot unilaterally just decide to stop paying medical bills. That opens the insurance carrier up to potential penalties under the Act. If the insurance carrier does not believe treatment is reasonable or necessary, there is a proscribed remedy in the Act, the insurance carrier must file a Utilization Review to have an independent doctor review treatment for reasonableness and necessity. That is the remedy. Unilaterally not paying medical bills is a violation of the Act.

Finally, and one final work on unpaid medical bills, it is also critical that you understand and know exactly what is happening to unpaid medical bills prior to settling your claim. If you settle your claim without medical bills being addressed or paid, they will become your responsibility. Remember the golden rule on settlement. Once you settle, your claim is closed forever and can never be reopened.

As you can see, unpaid medical bills can turn into quite complex legal arguments that require litigation and testimony of doctors. That is precisely why you need experienced workers’’ compensation legal representation on your side. Mooney Law is a has decades of litigation experience in Pennsylvania workers’ compensation. You can call us today at 717-200-HELP or 717-632-4656 to schedule a FREE CONSULTATION. Additionally, you can complete the Schedule a Consultation form on our website. We are ready to help you.

Mark Buterbaugh

Attorney representing injured workers and Social Security Disability clients in Pennsylvania and Maryland.