Workers’ Compensation Medical Expenses And Rehabilitation
Workers’ compensation in Wisconsin compensates those who have suffered from on occupational disease or injury in part by covering all medically-necessary and reasonable medical expenses, plus physical and vocational rehabilitation if needed.
Medical expenses make up more than 60 percent of all workers’ compensation benefits paid out by Wisconsin work injury insurers. The law requires carriers to pay for all treatments that are reasonably required to cure and relieve a worker who is injured from the effects of that injury (or illness). This is true regardless of whether a worker has lost time or wages or has suffered disability. As outlined in Wis. Stat. 102.42(1), payments can include coverage for:
- Medical, surgical, chiropractic, psychological, podiatric, dental and hospital treatment;
- Medical and surgical supplies, crutches, artificial members, appliances and training in the use of these effects;
- All reasonable expenses incurred by or on behalf of employee in providing such treatment, medicines, supplies and training;
- Invasive treatment undertaken in good faith by an employee for a compensable injury where such treatment is medically acceptable but not necessary.
The workers’ compensation claims process is complex. Lein Law Offices is available to help. As our Hayward workers’ compensation attorneys can explain, ailing workers may be required to submit a request to insurer for pre-approval for medical treatment. Workers have the right to a choice of first or second doctor, but failure to notify employer may result in delay or denial of benefits. Although few employers dispute the need for emergency treatment, they can and often do dispute other treatment on grounds that either the fee is unreasonable or the procedure is not medically necessary.
Treatments that are specifically excluded include those provided by a physical therapist, masseur/ masseuse or pain clinic unless such treatment is ordered by a physician or the employer/ insurer specifically agrees in advance.
Whether a medical fee is “reasonable” is explained both in Wis. Stat. §102.16(2m) and Wis. Admin. Code §DWD 80.72. Necessary treatments must be paid unless the claim is settled through a compromise agreement, as approved by the division.
Disputes may require a formal hearing, so it’s best to hire an experienced workers’ compensation lawyer if this is the situation you face.
How Is Reasonableness And Necessity Determined?
Approval from the workers’ compensation insurer must be obtained for treatments, such as surgery, to allow the insurer to consider whether it’s reasonable and necessary before paying. Insurers are notorious for seeking out any means by which to deny treatments – especially expensive procedures.
Your doctor/ health care provider must file paperwork with the Department of Workforce Development, including a form WKC-9498 reasonableness of fee dispute resolution request.
An insurance company may have you undergo an “independent medical examination.” This is not actually an “independent” process, but rather involves a physician who is paid by the insurer, and who is keen to find evidence the treatment you seek isn’t medically necessary or reasonable. If the medical opinions of the two doctors differ, the dispute will need be resolved by a workers’ compensation administrative law judge at a hearing.
Your workers’ compensation attorney should be prepared for that hearing seeking prospective treatment with documentation of:
- Medical opinion that treatment proposed is necessary to cure and relieve worker from injury effects;
- Identify the exact nature of the treatment or procedures sought.
Although exacerbations from a work injury can qualify a worker for benefits, an unrelated pre-existing condition or disability will not. If workers are more susceptible than normal to a work injury because of a pre-existing condition, employer is nonetheless liable for cover costs for treatment of the injury, to the extent the injury accelerates or aggravates the pre-existing condition.
Vocational Rehabilitation from Wisconsin Workers’ Compensation
If you can’t go back to work in the same capacity as before due to permanent disability or limitations, you could be eligible for services of vocational rehabilitation. These encompass retraining and job placement assistance.
Eligibility for vocational rehabilitation includes:
- Compensable, work-related injury and vocational rehab benefits haven’t yet been set through the process of a compromise agreement.
- Documentation and submission of specified work-restrictions, giving employer the ability to ascertain whether work is available within your permanent restrictions for an offer of “suitable” employment, which must be extended within 60 days. A position that is “suitable” allows for up to 90 percent of one’s previous wages and meets the specified work restrictions once one has attained maximum medical improvement (i.e., a healing plateau). If a worker can’t receive services from the Division of Vocational Rehabilitation, a position that is “suitable” would mean one wherein employee is paid at least 85 percent of prior wages AND meets the requirements for permanent work restriction by the time they’ve reached maximum medical improvement.
- Being unemployed or in a position that is “less than suitable.”
- Determined to be eligible for vocational services by the vocational services department.
These services can be provided by either a private or public source, whichever has the capacity to provide for your disability and vocational needs. If your employer or workers’ compensation insurer doesn’t dispute the need for vocational services or employment retraining, they are responsible for paying the weekly temporary total disability benefit for the time you are receiving education or retraining. They must also provide reimbursement for mileage commuting from school, books, tuition, meal allowance and other related expenses.
If you have questions about payment of medical expenses or vocational services through your workers’ compensation, our experienced legal team can help.