When a worker is injured on the job in Massachusetts, he or she often requires medical treatment. While the employer’s workers’ compensation insurance company is responsible to pay for the medical treatment, sometimes they deny the treatment and refuse to pay. The insurer typically undertakes utilization review to decide whether to authorize and pay for the medical treatment. Even when treatment is denied, the injured employee is not out of options. Below is a summary of medical benefits, the utilization review process and the injured worker’s options.
Workers’ Compensation Insurer Has a Duty to Provide Medical Treatment to Injured Workers
Under Massachusetts law (M.G.L. c. 152 §§ 13, & 30), when a worker is hurt on the job and requires medical attention, the workers’ compensation insurer has a duty to cover the cost and expense of the medical treatment. This is true regardless of whether the injured employee is incapacitated or disabled. The payment of the costs and expense of treatment is considered a medical benefit, which is a type of compensation under the law. This obligation by the insurer, however, is not absolute. All medical treatment sought by the injured worker or requested by a medical provider must be related to the work injury and found to be reasonable and medically necessary. In most situations, utilization review is performed by the insurer before authorizing and paying for the medical treatment.
Understanding Utilization Review in Workers’ Compensation Cases
Generally, an injured worker in Massachusetts must seek approval from the workers’ compensation insurer before receiving medical treatment. A medical provider will usually not provide treatment until the insurer has authorized it. When medical treatment is sought or requested, the insurer will commonly undertake utilization review.
Utilization review is an oversight process that is required by law in Massachusetts. This process assures that the medical treatment or services sought by the injured worker or recommended by a medical provider is related, reasonable and necessary. When the workers’ compensation insurer undertakes utilization review, they typically use a medical professional to review the requested medical treatment for the injured worker to determine if it meets the legal requirement of being related, reasonable and necessary.
When the utilization review finds that the proposed medical treatment meets the statutory requirements of being related to the work injury, reasonable medical service and medically necessary, they will authorize the treatment. In this case, a determination letter will be issued by utilization review approving and authorizing the medical treatment. Provided there are no issues regarding liability or causal relationship, the insurer will generally pay for the authorized treatment.
On the other hand, if utilization review determines that the requested medical treatment fails to meet the legal requirements, they will issue an adverse determination letter denying the medical treatment. In the adverse determination letters, the utilization review agent should provide information about their appeal process and procedure. Usually, the requesting medical provider or doctor will initiate the appeal.
The Injured Worker’s Options When Medical Treatment is Denied
When medical treatment is denied by the workers’ compensation insurer, the injured worker has certain options. As stated above, if utilization review issued an adverse determination letter, it should include information on how to appeal the denial of authorization for the medical treatment. Usually, the requesting medical provider will initiate the appeal to utilization review.
The injured worker also has the right to file a claim for benefits. An employee’s claim for medical benefits are filed in the same way that a claim for disability benefits are filed. The claim is filed with the Department of Industrial Accidents in Massachusetts and will proceed under the same workers’ compensation process as other claims.
It is always best for an injured worker to speak with an experienced workers’ compensation attorney in Massachusetts. The process, procedure and laws for workers’ compensation claims and cases can be quite complex. There are many requirements of filing and litigating an employee’s claim. Failing to meet the requirements can result in significant delays and, sometimes, a denial of a claim. An experienced lawyer can help explain the workers’ compensation process, answer questions and guide an injured worker through a claim for benefits.
Have You Been Hurt on the Job? Call Today to Speak with our Legal Team.
Mahaney & Pappas, LLP specialize in helping injured workers in Massachusetts get the workers’ compensation benefits they deserve. If you feel that you are not getting the medical treatment or disability benefits to which you are entitled, feel free to call us at (508) 879-3500 or contact us online to schedule a free case review.