What must the Insurance Company pay for?

When you are injured on the job and need to seek medical treatment, how much of that treatment is covered by your employer’s workers’ compensation insurance? Most injured workers know they have access to wage loss benefits and compensation for medical expenses, but then comes the question of exactly what counts as a medical expense?

Are medical devices such as canes and wheelchairs covered? Prescription medications? Transportation to and from appointments? And what about visits to your personal doctor who is not one of the valid panel doctors listed by your employer? These are just some of the questions which will be answered in this breakdown of what counts as a medical expense covered by workers’ compensation.

Medical Devices may be Covered

Wheelchair

Medical devices may be covered by the insurance company on a case by case basis. Whether or not your medical devices are covered will mainly depend on two things: the severity and type of your injury, and the opinion of your treating physician. For example, if you broke your leg in a workplace fall, and this fact is not disputed, the insurance company may be more willing to compensate you for the wheelchair you require. Additionally, your treating physician can provide the insurance company with a written statement or prescription opining that the wheelchair, crutches, or other medical device is medically necessary in relation to your work injury.

Sometimes the insurance company will accept to pay for medical devices merely because they are presented with a receipt. Other times you may have to do a bit of extra work gathering written statements from your doctors. And yet there may still be times your request for compensation of such devices is denied outright. An experienced workers’ compensation attorney can help give you the best chance to receive the compensation you deserve from your employer’s insurance.

Prescription Medicine will be Covered

prescription medication

While medical devices may or may not be covered depending on the specifics of your case, insurance companies are responsible for covering your reasonable, necessary, and related prescription costs associated with your work injury. However, they will sometimes cause delays which can have a negative affect on your recovery time and comfort level. Luckily, there are workers’ compensation prescription companies that can help overcome such delays.

If you decide to pay out of pocket for your prescriptions, the insurance company is required to reimburse you for this. However, there are often extensive delays when it comes to this reimbursement due to the levels of bureaucracy within the insurance company. For this reason, paying out of pocket is usually not recommended, but it is still a viable option if you need your medications immediately. In some cases you will be given a prescription card to use by your employer’s insurance. Using that may be the easiest option, but they are not always activated and there can be delays in filling your medications at times.

Off the shelf medicine is another entity entirely. The insurance is not generally responsible for covering any off the shelf medications you take. Those costs will usually fall on you.

Transportation to and from Appointments may be Covered

partial disability benefits

In most cases, transportation to and from doctor’s appointments associated with your work injury is paid for by you, not the insurance carrier. You can attempt to have the insurance company reimburse you for your travel if your work injury itself prevents you from driving or if appropriate medical care is not located reasonably near where you live. But there is no guarantee the insurance company will comply barring an order by a judge to pay for your transportation.

In order for a judge to determine whether the insurance company must pay for your transportation many factors can be considered. The greatest factors will generally be how far you have to travel outside your local area in order to reach your doctor’s appointments and whether other doctors are available closer to you. And even then, reimbursement for such transportation costs will be determined on a case by case basis.

The one time you will be guaranteed reimbursement for your travels is regarding transportation to and from Independent Medical Examinations (IMEs). Since these examinations are requested by the insurance company for the insurance company, they must bear any and all costs associated with them — including, but not limited to, transportation.

Doctors Your Select Rather than Panel Doctors May be Covered

Medical treatment

If a company has created a valid panel list and complies with all technical requirements of the Act, the insurance company will likely not pay for you to see any doctors who are not on your employer’s valid company physician list for the first 90 days. After those 90 days, they will likely have to pay regardless of which physician you visit. Because of this, many injured workers opt to begin seeing doctors of their choosing after this time limit has expired.

However, if your employer does not have a valid list of panel doctors, then the 90 day rule does not apply. In such a case, the insurance company would have to pay for whichever doctor you choose to treat with from the start. To determine what your options are, it is important that you consult with an experienced workers’ compensation attorney.

Additionally, if you choose to treat with a physician outside the state of Pennsylvania, this can complicate your billing and create balance billing problems for you. It is not recommended that you treat with an out of state provider without first understanding what that could mean and without discussing it with the provider’s office.

Conclusion

When it comes to medical expenses paid for by your employer’s insurance, things can get a bit complicated. Medical devices may be paid for, but only on a case by case basis. Prescriptions will be paid for by insurance, but off the shelf medications will not. Additionally, costs associated with transportation to and from doctor’s appointments are not guaranteed to be reimbursed with the exception of IMEs. Finally, the insurance company may not have to pay for treatment with non-panel physicians within the first 90 days after your injury if they have set up the panel correctly.

Contact Hillsberg Law

If you have been injured at work, a workers’ compensation attorney can improve your chances of receiving a full and fair compensation for your injuries. My name is Geoffrey Hillsberg, and I have been solely practicing workers’ compensation law in the state of Pennsylvania since 1995.

Contact my law office for a free consultation regarding your case.


The advice offered above is general in nature and may not be applicable to every case. Consultation with an attorney is highly recommended. Reliance on this advice does not represent the formation of an attorney-client relationship in the absence of a fee agreement with Mr. Hillsberg.