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How Do Workers’ Comp Medical Benefits Work?

Overview of Texas Workers' Compensation Benefits:

According to the Texas Labor Code, injured workers whose employers participate in the Texas workers' compensation program are entitled to workers' compensation medical benefits. But just like any insurance claim, if you've been injured on the job, you may encounter difficulty having certain procedures or treatments approved by the insurance company.

In this article we will discuss what the Texas labor code says regarding workers' compensation and what that means for your work injury claim.

Questions Answered on This Page:

  • How does workers' comp work in Texas?
  • What medical benefits are available through workers' comp?
  • How do I find out what medical benefits I have if I've been injured on the job?
  • Does my employer have to pay for my emergency room visit?
  • If my employer has workers' comp, how do I file a claim?

What Texas Law Says About Your Right to Medical Attention

Your right to medical attention, provided that your employer is a subscriber to worker's comp coverage, is outlined in the Texas Labor Code. The statute states that if you are injured while working on the job, your employer's worker's compensation coverage will pay for all necessary medical care (provided that you didn't injure yourself on purpose, etc.). It specifically lists types of care you are absolutely entitled to receive.

There are essentially three goals of medical care as covered by worker's compensation:

  1. Fix the injury or alleviate the damage caused by the accident
  2. Receive care which promotes recovery
  3. Enhance your ability to return to work and keep your job

Therefore, if your injury can be fixed or alleviated in any way and this would aid in your recovery and increase your chances of returning to work, then your worker's compensation should cover that cost.

Here's an Example:

Let's say that you have a foot injury at work that ultimately leads to an amputation. Is your medical care covered by worker's compensation?

First, is the surgery to amputate your foot and the subsequent recovery time at the hospital covered? Yes, because if the surgery cured or relieved the effect of the injury and the hospital stay promoted your recovery, these costs should be covered. But losing your foot now presumably prevents you from working in the same capacity. Should worker's compensation pay for you to receive a prosthetic foot? Yes. Since your work injury ultimately led to the loss of your foot, the only way to cure this injury is to replace it with a prosthetic foot. This not only helps to relieve the effect of the injury, but it also promotes recovery, and greatly increases your ability to return to work if that is a possibility.

But it's not usually so simple...

The thing is, many aspects of workers' compensation benefits in Texas are based on two less-than-stellar resources called the Guide to the Evaluation of Permanent Impairment: AMA 4th Edition and the Official Disability Guideline commonly referred to as the ODG. So if you're work-related injury was looked at by a reasonable doctor, that could result in you being prescribed "Treatment A" according to current understandings and practices in medicine. But if the same injury is looked at by a workers' comp approved doctor, and the guide calls for "Treatment B", that's the treatment you'll receive, regardless of changes in practice.

Ways in Which Insurance Companies Will Try to Deny Your Workers' Comp Medical Benefits

So, if all of your treatment seems fairly straightforward and simple, how can an insurance company even begin to try and deny your coverage? First, the insurance company will insist that you receive all of your treatment from a worker's compensation approved doctor. The relevant statute says that workers are "entitled to all health care reasonably required." What you may consider to be reasonable healthcare could be seen as unreasonable by a doctor who is paid by the workers' compensation insurance carrier (or the carrier themselves). In this case, having an attorney on your side is helpful because we have expert witnesses and damages experts who will testify to the degree of healthcare that you require, even if the worker's compensation program declares otherwise.

Many insurance carriers will also attempt to deny your claim by arguing that you do not actually need all of the treatment you are seeking and give you hard time about your pain medication and prescriptions. Recall the example we used above. They might argue that you do not need a prosthetic foot due to the availability (and lower cost) of wheelchairs or crutches. Or, they might attempt to deny your worker's compensation income benefits and force you to go back to work too soon. By forcing you back to work too soon, you could greatly hurt your recovery process which can ultimately cause you more harm. If you are not yet proficient in walking around or balancing on your new foot, you could injure yourself even worse while at work.

How Grossman Law Offices Can Help

In this situation, you need an experienced worker's compensation attorney who is familiar in handling worker's comp coverage claims and knows how to deal with these pushy insurance companies. The law was specifically written to protect your rights as an injured worker and without adequate representation, you may not receive all of the medical care you need, which could ultimately cause even greater harm due to the insurance company's underhanded attempts to deny your compensation.

To learn more about your rights to medical care under worker's compensation, contact Grossman Law Offices at (855) 326-0000.

Other articles about worker's compensation that may be helpful to you:

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