Once an employee has a compensable case as outlined herein, the employee has numerous entitlements to benefits. Medical treatment that the employee may seek may include but are not limited to hospital charges, nursing charges, doctor visits, surgical charges, medications, durable medical supplies, prosthetic devises, physical therapy, mileage reimbursements for travel to medical providers and in some cases 24 hour nursing care. This is not to say the insurance company will blindly pay for all treatment that is recommended by a doctor.
In most cases the insurance company will question and possibly deny the medical treatment for one or more of the following reasons:
- if they believe that the treatment is not causally related to the workers compensation accident;
- there is a new accident or injury;
- the claimant has reached maximum medical improvement(in the view of one doctor);
- the treatment is expensive, excessive or not reasonable in their mind.
Most of the time, the employer will require a statement from the treating doctor which sets out the treatment that is being proposed. In some cases, the employer/insurer will send the claimant for an independent medical evaluation to determine if they want to pay for the requested medical treatment. The insurance company has the right to set the claimant up for an independent medical examination. This is an examination will usually determine whether the insurance company will continue benefits or cut off benefits. In rare cases, the Maryland Workers Compensation Commission will order a medical exam. Currently, in Maryland there is a schedule of fees that sets out the compensation due to medical providers for services performed. The medical providers must accept what the fee schedule determines is the correct payment. Injured workers may have difficulty finding a medical provider outside of the state to accept them for treatment. The out of state medical providers are likely not familiar with the fee schedule and will be reluctant to agree to accept a patient under those terms.
If the Employer/Insurer deny treatment, issues will need to be filed with the Maryland Workers Compensation Commission to get a hearing and have the issues decided by the Maryland Workers Compensation Commission. The Claimant and/or Claimants attorney must be sure to have an outline of the treatment that is being recommended along with a statement of causal relationship and how this treatment is directly related to the accident for which issues are being filed. The Claimant’s doctor will need to be a specific as possible because the employer/insurer will surely have a defense to the medical treatment that they will submit at the hearing. The employer/insurer will have a defense medical examination that will likely claim the medical treatment is not causally related, not reasonable or necessary or that the claimant has reached maximum medical improvement and is not entitled to additional medical treatment.
If the treating physician recommends treatment, and the claimant chooses not to undergo the treatment, the employer/insurer will likely argue that the claimant has reached maximum medical improvement.
In the District of Columbia, treating physicians are afforded a presumption that gives their opinions extra weight of that of a non treating physician. This presumption does not exist in Maryland.