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

Bradt Law Offices Case Report: Ankle Injury on a Flat, Dry Floor

Type of Case: Workers’ Compensation

Legal Issue or Dispute: Denial of ankle injury claim which occurred at work

Facts: Our client was employed with one of the mining companies in northern Minnesota. His job duties required him to maintain and repair equipment within the facility. On the day he was injured, one of the machines in the plant malfunctioned and began to spew waste material into the air and onto the plant floor. Our client received a radio call to get to the machine, evaluate the problem and assist in any maintenance or repairs which might be necessary.

As he was hurrying across the concrete plant floor and approaching the malfunctioning machine, he rolled his ankle and suffered a severe ankle sprain. The floor was not wet and he did not recall stepping on, or tripping over, any hoses or other debris. He wasn’t even sure what happened except that he was hurrying because of the emergency and was looking up at the malfunctioning machine rather than at the floor.

The claim was completely denied by the employer and its workers’ compensation insurer on the grounds that the injury was not related to the employee’s work activities because he was simply walking across the plant floor at the time of the injury and there was no unsafe or dangerous condition in the plant or on the premises which caused the injury.

The case proceeded to trial before a workers’ compensation judge where we argued that the employee’s work environment caused or contributed to the injury because he was hurrying to deal with an emergency situation and not paying attention to the floor. His job duties required him to deal with the malfunctioning machine as quickly as possible and those factors are what caused or contributed to the injury.

Result: The compensation judge ruled in favor of our client and determined that his ankle injury was covered by workers’ compensation. The case was appealed by the employer/insurer and the Minnesota Workers’ Compensation Court of Appeals affirmed the judge’s decision and awarded benefits to our client.

The insurance company was also required to pay our attorney fees and costs.

If you have questions about any aspect of your northern Minnesota work comp claim, please feel free to contact me at Bradt Law Offices at any time. I am happy to speak with you about your claim or make an appointment for an absolutely free consultation in our Grand Rapids office or wherever it would be convenient for you. We have been representing your friends and neighbors on their work comp claims all across northeastern Minnesota and the Iron Range for more than 30 years. If you’ve been injured, we can help.

Thank you for visiting our blog.

What Should I Do If I Receive a Notice of Intention to Discontinue Benefits on My Minnesota Work Comp Claim?

At some point in almost any work comp claim where you are paid wage loss benefits, you will receive a Notice of Intention to Discontinue benefits, commonly referred to as an NOID. An NOID is simply a form which the insurer is required to serve and file whenever they will be discontinuing wage loss benefits. The form provides you with notice that your benefits will be ending at a certain time and explains the reason why.

Some reasons why you might receive an NOID form

1. You have returned to work. If you have been off work and receiving wage loss benefits from work comp, you have been receiving Temporary Total Disability (TTD) benefits. These benefits are paid at the rate of 2/3 of your average weekly wage on the date of injury. (For more information on TTD benefits, see our blog post here)

The notice tells you that the insurance company will be discontinuing those benefits because you are back to work and no longer entitled to TTD benefits. If you are returning to work, with restrictions from your injury but earning less than your preinjury wage, you may be entitled to partial wage loss benefits (TPD) and the NOID form should reflect that you will be paid TPD benefits upon returning to work. It doesn’t matter whether you are going back to work for the same employer or whether you have found a new job since the injury.

2. You have exhausted your TTD benefits. For dates of injury between 10/1/95 and 9/30/08, you are limited to 104 weeks of TTD benefits. This means that even if you are still out of work because of the injury, you cannot receive more than 104 weeks of TTD and your benefits will end. For injuries on or after 10/1/08, the maximum number of TTD benefits was increased from 104 to 130 weeks.

3. Your weekly earnings have reached or exceeded your preinjury wage. If you have been working at a wage loss and receiving TPD benefits, those benefits will end once you get back to your preinjury wage, because you no longer have a wage loss.

4. You have reached Maximum Medical Improvement (MMI). If you are receiving TTD benefits, those benefits will end 90 days after you are provided with notice that you have reached MMI. An MMI opinion can come from one of your treating physicians or from a doctor who has examined you for the insurance company (this is called an Independent Medical Exam (IME), more information about an IME can be found here). The explanation for why your benefits are being discontinued must be included on the NOID form.

5. You no longer have work restrictions. If your treating physician, or the IME doctor, gives an opinion that you have no work restrictions as a result of the work injury, you are no longer eligible for wage loss benefits. Most often, this occurs following an IME where the insurance company doctor writes a report and gives the opinion that you have fully recovered from the work injury or that any restrictions you have are not related to the work injury. Sometimes, your own doctor may lift all restrictions without fully understanding how this might affect your claim. (For more information about choosing a physician for a work comp claim, click here).

What you can do if you receive an NOID

Your options after receiving an NOID are explained on the form and will depend upon the reasons for the discontinuance. If you disagree with the discontinuance of benefits or the reasons given, you can request a telephone conference with a work comp judge to argue your position. The time frame to dispute a discontinuance if you want an immediate conference is generally 12 days. The NOID form provides you with a phone number and address and explains how to request the conference.

If you have an attorney, you should obviously make sure that he or she has received a copy of the NOID form and will be requesting a conference on your behalf if you disagree with the discontinuance of your benefits. If you don’t have an attorney, this would be a very good time to contact one. At the discontinuance conference, the insurance company will be represented by either a claims adjuster or an attorney. The discontinuance of your benefits is a serious matter and you should have an experienced work comp attorney representing you at that conference.

If you win at the conference and the judge agrees that your benefits should not be discontinued, the insurance company may appeal but they will have to continue paying your benefits until a formal hearing is scheduled. However, if you lose at the conference, you may appeal but you will not receive any benefits while you wait for the formal hearing and a decision. Having an attorney represent you at the initial conference will generally give you a much better chance to win.

There are some other reasons why your benefits might be discontinued, but these are the most common situations that we typically see.

Contact Us If You Have Questions about Your Claim

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. If you have questions or concerns about the cost of hiring an attorney, you can check out this previous post- How much does it cost to hire a workers’ compensation lawyer in Minnesota?

At Bradt Law Offices, we have been providing assistance to injured workers all across northern Minnesota and the Iron Range for more than 32 years.

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

excellent NPR investigative series–injury to insult:America’s vanishing worker protections

Click on this link to read an excellent investigative series of articles which highlight a new scheme by corporate America to avoid participation in state regulated Workers’ Compensation programs which often result in disastrous consequences for men and women injured on the job.

Beware of a New Attack on Benefits for Injured Workers

It’s  bad enough that state legislatures, including ours right here in Minnesota, have chipped away at the rights and benefits of injured workers over the past 30 years. Now, some states are getting rid of workers’ compensation altogether and creating their own systems for compensating workers injured on the job. The argument made by business owners is, of course, that this is good for the injured working man or woman. Don’t believe it. If it’s being proposed by business you can bet that the motivation is strictly the bottom line – employers save money and the injured worker loses rights and benefits.

For more details about this scary prospect and how it is happening in other states, click on the link to read this excellent article : Inside Corporate America’s Campaign to Ditch Workers’ Comp.

As a work comp attorney representing injured workers for more than 30 years here in northern Minnesota, I find this to be a very scary development. If it is being pushed through in other states, you can be assured that it may eventually be tried here. Please feel free to share this article with anyone you feel might be interested.

Thank you for visiting our blog and please feel free to contact us at any time if you have questions about a work comp claim or would like to set up a free consultation to discuss your rights if you’ve been injured on the job in Minnesota.

What Is the Difference Between a Settlement Conference and Mediation in a Minnesota Work Comp Case?

Over the past several years we have seen the increasing use of mediation to settle work comp cases in Minnesota. If you have a work comp claim, you may wonder why a settlement conference was scheduled on your case but a mediation has then been proposed or scheduled. What’s the difference, and is one better than the other?

Settlement Conferences

Settlement conferences are automatically scheduled by the workers’ compensation Office of Administrative Hearings after a claim is filed.

In every work comp case where a Claim Petition is filed, a settlement conference is automatically scheduled for approximately 6 months later. Depending upon where you live, these conferences may be scheduled by telephone or may take place in person with a work comp settlement judge in St. Paul. A settlement conferences is an informal opportunity for the parties to attempt to settle any disputed issues and sometimes the entire claim.

Settlement conferences are scheduled to last one hour and a work comp judge presides over the conference to help the parties reach a settlement. It is not a trial and the judge does not have any authority to order the parties to agree to any particular terms, nor does the judge have authority to make any decisions about the disputed issues. If the claim does not settle, it will be put on the trial calendar for a hearing a few months later with a different judge.

Frequently, settlement conferences are either postponed or canceled altogether. A conference may be postponed because it is too early in the case to discuss settlement, possibly because of pending surgeries or ongoing medical care which needs to be completed. In other cases, the parties may agree that there is no possibility of settlement and ask that the case be put on the trial calendar for hearing. This may occur in cases where the insurance company has denied liability for the claim or where there is a dispute over a proposed surgery or medical procedure. In these types of cases, there may be no room for compromise and the disputed issues need to be decided by a judge.

If a case is settled at a conference, the defense attorney will prepare a Stipulation for Settlement, which sets forth the terms of the agreement. All necessary parties must sign the Stipulation and it is then submitted to a compensation judge for approval before the insurance company makes payment.

Mediation

A mediation is also a method to get the case settled but it is more formal and involved than a simple one hour settlement conference. Typically, the parties agree to mediate cases that are more complicated or have more value. The parties will choose a mutually agreeable mediator who is experienced in Minnesota workers’ compensation matters. The mediation may take place at the mediator’s office, at one of the attorneys’ office or at a neutral site depending upon the availability of conference rooms and where all the parties live or work.

Prior to the mediation, the employee or her attorney will submit a detailed case evaluation and settlement proposal to the insurance company. Both parties will also submit confidential background information to the mediator before the mediation so the mediator understands the issues, the claim values and the relative position of each party.

Once the mediation begins, the parties will usually be in separate conference rooms and the mediator will visit back and forth between the rooms with settlement offers and counter offers. The process may take part or all of the day until the parties either come to an agreement or determine that they cannot agree on a settlement amount or terms. Most mediations will probably be completed in 2-4 hours.

If no settlement is reached the case simply continues toward a hearing on the disputed issues and all discussions, offers or counter offers remain confidential and cannot be discussed or used at any later hearings. Essentially, there is no risk in pursuing a mediation and it is often a good way to find out how each party is valuing the case, even if a settlement is not reached. If nothing else, you will find out what the insurance company is willing to pay to settle your claim at that time. The value of any claim might increase or decrease after the mediation, depending upon medical, employment or other factors.

If a settlement is reached at the mediation, the process is the same as for any other work comp settlement. A Stipulation for Settlement is prepared, signed by the parties and submitted to a work comp judge for approval.

Do I Need an Attorney for a Mediation or Settlement Conference?

Technically, any employee may represent himself in a work comp claim at a settlement conference, mediation or even at a trial. However, keep in mind that the insurance company has experienced claims adjusters and attorneys looking out for their interests. Also, the insurance company’s interests are not the same as yours, so it is not reasonable to expect that they will voluntarily pay you a fair settlement if you are not represented by an experienced attorney.

In any type of work comp case, particularly where there are discussions about settlement or disputed issues, it is a good idea to consult with an experienced attorney to make sure you understand your rights and are being treated fairly by the insurance company.

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. If you have questions or concerns about the cost of hiring an attorney, you can check out this previous post- How much does it cost to hire a workers’ compensation lawyer in Minnesota?

At Bradt Law Offices, we have been providing assistance to injured workers all across northern Minnesota and the Iron Range for more than 30 years.

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