Can the Insurance Company Refuse to Pay Medical Bills after a Minnesota Workers’ Compensation Settlement?

This is a question I frequently hear not only from clients but also from people who have settled a claim, with or without a lawyer, at sometime in the past. In fact, sometimes many years have gone by since the settlement before this issue arises and I receive a phone call. The question is usually something along these lines:

“I settled my work comp case but medical was left open, now the insurance company won’t pay for a doctor visit (or an MRI, surgery, etc. ) – how can they do this?”

This can be a very confusing issue after the settlement of a work comp claim, whether or not you were represented by an attorney. It would seem, from a common sense standpoint, that if future medical coverage was supposedly “left open” for your work injury, then the insurance company should have to pay any future medical bills. However, it’s not quite that simple, for several reasons:

1. The work comp insurance company always has the right to challenge whether medical treatment is reasonable, necessary and related to the work injury.  Regardless of whether an injury claim is accepted, decided in your favor by a judge or settled, the insurance company is not obligated to pay every medical bill without question. The burden of proof remains on the injured employee in a Minnesota work comp case, which means that you have to prove that any disputed medical treatment is reasonable, necessary, and related to the work injury.

This typically requires some medical support for your claim, either in the form of medical records which clearly explain the situation or in the form of a medical report from a treating physician which addresses the disputed issues and supports your position. For this reason, it is very important to have a doctor who not only understands the work comp system but is also willing to support you, if necessary, with a letter or medical report. (For more information about selecting a doctor in a work comp case, see our previous blog post here).

2. Months or even years have passed without treatment for your injuries. If you haven’t treated for your work injury in a long time, the insurance company will not have any up-to-date information regarding your claim and they will want to make sure that the medical care is still related to the work injury. Sometimes, all the insurance company needs is updated medical records which will demonstrate that your physicians are still relating your treatment to the original work injury. If the medical records do not clearly make that connection, it may be necessary to get a letter or report from your doctor. In any event, the insurance company is entitled to get updated information before deciding whether to pay a medical bill or authorize treatment.

3. You have been back to work for a different employer since the settlement. The insurance company will likely want to make sure that you haven’t had a new injury or that your new job has not aggravated the injury that was covered by your previous settlement. Again, particularly in a case where you haven’t made any medical claims for some period of time, the insurance company will need updated information before making a decision on any medical bills. In fact, if you have returned to work in a different job and your symptoms have increased or worsened, you may very well have a new work comp claim against your new employer for a permanent or substantial aggravation of your underlying medical condition.

4. Your current problems were not specifically addressed in the settlement agreement.  Let’s assume that the original injury and settlement involved your left shoulder and you are now having problems with your left elbow. Your doctor suspects that the elbow problems may be coming from the shoulder or are somehow related to the shoulder injury. The language in the settlement papers describing what injuries were covered will be very important. In this type of case, it may come down to arguing about whether the elbow problems are related to the shoulder or whether they represent a new, unrelated problem. These types of issues arise frequently and are normally going to be the subject of litigation.

5. The medical treatment being denied was closed out under the terms of the settlement.  The settlement papers you signed (a Stipulation for Settlement) described the injuries and claims you were making, the claims or defenses of the insurance company and the terms of the settlement. In many cases, even where future medical remains open, there is an agreement to close out certain, limited future medical treatment such as acupuncture/acupressure, massage therapy, health club memberships, psychiatric/psychological treatment, etc. This means that the insurance company is no longer responsible for any of those types of treatment even if they are related to your original injury.

Also, medical treatment for specific body parts may have been closed out by the terms of the settlement if there were disputes over the nature and extent of your original injuries. For example, you may have originally claimed an injury to your neck and low back but the terms of the settlement may have only left open future medical treatment for your neck, closing out any low back medical claims.

What you can do to help avoid disputes over  future medical coverage after a settlement:

-Understand exactly what body parts and what type of medical coverage remains open and what was closed out by the terms of the settlement;

-Keep a copy of your settlement papers for reference;

-Make sure any and all medical treatment for your injuries after a settlement is billed to the work comp insurer, not to your health insurance. This helps ensure that the work comp insurance company remains aware of your ongoing medical issues if something serious for expensive arises such as surgery or the need for an MRI;

-Make sure to always tell your physician that the condition you are treating for is related to a work injury and give as many details as you can, such as the date of the injury and what body parts were injured, so there is a paper trail of any ongoing medical care or treatment from your work injury.

These are just some of the potential medical scenarios which might arise after a settlement and some of the things you can do to lessen the likelihood of more litigation on your claim. It probably goes without saying that you should not settle a work comp claim without first speaking with an experienced work comp attorney.

If you have been injured on the job and have questions about the Minnesota work comp system, please don’t hesitate to give us a call. You can contact us, anytime, with questions about your case or to arrange an absolutely free consultation. It won’t cost you anything and we will always give you our honest assessment about whether you need a lawyer to represent you.

Remember, you are dealing with an insurance company which handles hundreds or thousands of claims every day. They have experienced claims adjusters and attorneys managing their files. Even if you don’t need a lawyer at the moment, a little information about the work comp system can make a big difference for you in your dealings with the insurance company. At Bradt Law Offices, we have been providing assistance to injured workers all across northern Minnesota and the Iron Range for more than 33 years.

As always, thank you for visiting our blog and please spread the word that we are a good source of work comp information and assistance for workers injured in northern Minnesota and anywhere on the Iron Range

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