If Medical Benefits Remain Open For Life After A Lump Sum Settlement in Massachusetts, Why Is Your Treatment Denied?

When a workers’ compensation claim in Massachusetts is resolved by way of a lump sum settlement, a judge at the Department of Industrial Accidents (DIA) must approve the settlement. An agreement for a lump sum settlement is presented to the judge and if it is approved, the judge will explain a few conditions of the settlement and claim to the injured worker.

One matter that the judge will explain to the injured worker is that, if the claim is settled with liability (either being accepted by the insurance company or established in the claim) the medical benefits remain open and available for the remainder of the injured worker’s lifetime. But, in some circumstances, although the medical benefits remain open, the insurance company may not always approve the medical treatment requested by the injured worker’s treating doctors.

What Does It Mean For Medical Benefits To Remain Open For Life

As stated above, if a workers’ compensation claim is settled by way of a lump sum settlement with liability, the medical benefits portion of the claim remain available to the injured worker. Unlike disability benefits, which are completely closed out after a lump sum settlement (e.g., the injured worker is not entitled to any additional disability or incapacity benefits beyond what he or she received in the settlement).

In this case, the medical benefits remain open for the duration of the injured worker’s life. The lifetime medical benefits, of course, are conditional upon satisfying certain requirements according to the Massachusetts Workers’ Compensation Act (M.G.L. c. 152). The requirements are that the medical treatment sought must be causally related to the original work accident/injury and the requested treatment must be determined to be reasonable and medically necessary.

Your Options If Medical Treatment Is Denied After A Lump Sum Settlement With Liability

Even though medical benefits remain open for life doesn't always mean the workers’ compensation insurance company will approve or authorize any requested medical treatment. In a lot of situations, the insurance company may use the factors mentioned above (related, reasonable and medically necessary) to their advantage in order to deny medical treatment after a lump sum settlement is reached with liability and approved by the DIA.

For example, in a recent case I settled with liability for an injured worker, the insurance company is denying additional physical therapy prescribed by my client’s doctor. The insurance company is arguing that the requested physical therapy is not medically necessary, although they concede that it is related to the original work injury and is reasonable treatment.

Just because the workers’ compensation insurance company denies medical treatment doesn't mean the injured employee is out of luck. The injured worker still has the right to file a claim for medical benefits. This means that the injured worker can file a claim to seek an order from a judge at the DIA to force the insurance company to pay for the requested medical treatment.

In the claim for medical benefits, the injured worker bears the burden of establishing that the requested medical treatment is related to the original work injury and that it is reasonable and medically necessary. As part of the claim, it is always best for the injured worker (or his or her attorney) to obtain a letter or report from the treating physician to explain that the requested medical treatment is related to the original injury and why it is reasonable and medically necessary.

In the example above, since the insurance company has denied the requested physical therapy, I have filed a claim on behalf of my client seeking an order for medical benefits to pay for the physical therapy. A claim, such as this, would proceed through the normal process of a Massachusetts workers’ compensation claim.

This is also an example of how a workers’ compensation attorney can continue to represent and help an injured worker even after the lump sum settlement. If Attorney Chuck Pappas was the attorney in the original workers’ compensation claim, he will continue to fight to get his clients the medical treatment they need.

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