When a worker is injured on the job in Kansas or Missouri, he or she is entitled to collect workers’ comp benefits to pay for medical treatments, ongoing care, lost wages, and other expenses. Any injury that happens at work or illness caused by workplace conditions is automatically covered by workers’ comp insurance, including a violent attack by a co-worker or stranger.
However, the employer and insurance company do have a say in the nature and extent of the treatment you receive, and may require a utilization review to determine whether your treatments are medically necessary. A recent case in the news illustrates how this audit can be detrimental to an injured worker.
Victims of Workplace Attack Denied Benefits
In December 2015, a horrific terrorist attack on employees at the Inland Regional Center in San Bernardino, CA, left 14 workers dead and 22 seriously injured. Because those who were injured were on the job at the time of the attack, they were eligible for coverage under California’s workers’ compensation insurance program.
Immediate emergency care for gunshot wounds and psychological care for emotional trauma were covered by workers’ comp, but workers who needed ongoing medical and mental health treatments were recently denied benefits following a utilization review. Despite suffering from post-traumatic stress syndrome and other psychological effects of the terrifying incident, some workers report their benefits have been denied by the insurance company. While San Bernardino County leaders are working to get victims’ benefits back, workers injured in less high-profile incidents may not be so lucky.
How a Utilization Review Could End Your Benefits
If you were injured at work and are undergoing workers’ comp-approved treatment ordered by a doctor, you could be in danger of losing your benefits at any time.
Utilization reviews are often initiated when the insurer or employer receives a bill for an injured worker’s medical care and questions whether the treatment is reasonable or necessary. If some time has passed since the initial injury, a review may be conducted to ensure the worker is still indeed injured. Often, bills for mental health care and alternative treatments are questioned, even if they were ordered by an approved doctor.
The utilization review is conducted by a neutral third party, usually a doctor or other health care provider, who reviews the worker’s medical records and determines whether the treatment is medically necessary. If the reviewer concludes the treatments aren't necessary, the insurer will deny your claim for benefits. Sometimes, a decision is made based solely on whether medical records are received by the reviewer in a timely manner, so it's important that your doctor responds to the request quickly.
What You Risk Losing
If your workers’ comp benefits are denied following a utilization review, you risk losing the following:
- Coverage for medical care. This includes all costs for authorized medical treatment, prescriptions, and medical devices. There isn't a deductible, and all costs are paid by the employer or its workers’ comp insurance company.
- Payment for lost wages. If a doctor confirms you're unable to return to work because of your injuries, you'll be entitled to partial payment for your lost wages until you are able to return to work. The benefits provided are calculated at 66 2/3 percent of your average weekly wage, not to exceed a maximum amount set by law. The average weekly wage is based on your gross wages. The duration of these benefits depend upon the extent of your injuries.
- Survivor benefits. If a worker dies on the job, his family may be entitled to survivor benefits under workers’ compensation.
An Attorney Can Help
If you're having a hard time getting approval for workers’ comp benefits, or have had benefits denied following a utilization review, call the experienced worker’s comp attorneys at Kansas City Accident Injury Attorneys today. We can help you get on the right track to recovery.