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.

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.

Bradt Law Offices Case Report: Consequential Knee Injury

Type of Case: Workers’ Compensation

Legal Issue or Dispute: Consequential knee injury following a back injury

Facts: Our client suffered a low back injury in the course and scope of his employment. The injury was accepted by the work comp insurer and our client eventually had two back surgeries. Although the surgeries were successful, he was left with some ongoing weakness, instability and radiating symptoms down one of his legs. The instability caused him to occasionally stumble or lose his balance, which resulted in a twisting injury to his knee. After treating for several months, our client ultimately required knee surgery.

We submitted the knee injury medical bills to work comp, because the knee injury was a consequence of the original back injury. Predictably, the insurance company denied responsibility for the knee problems and we filed a formal claim. We obtained a report from the knee surgeon explaining how the knee injury was related to the back injury and the case was set for trial.

Result: Before trial, the insurance company agreed to accept the knee injury claim and paid all of the medical bills related to the knee injury and surgery. In addition, our client was reimbursed for his medical mileage and expenses, out-of-pocket medical bills related to the knee injury and the insurance company agreed to accept responsibility for any future medical care for his knee. Finally, the insurance company paid our attorney fees and expenses.

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 nearly 30 years. If you’ve been injured, we can help.

Thank you for visiting our blog.

Can the Insurance Company Deny My Minnesota Work Comp Claim Because of a Pre-existing Condition?

Unfortunately, the work comp insurance company can deny a claim on almost any basis, no matter how flimsy. This is how insurance companies avoid paying claims, because they know that a certain percentage of people will never hire a lawyer or pursue a claim if it has been denied. This is particularly true where the injured worker has health insurance or other benefits available – many people are simply afraid to call a lawyer or don’t know where to begin when their claim has been denied.

However, getting back to the original question: Can the insurance company deny your claim because of a pre-existing condition? The answer is “maybe”. A pre-existing condition may have some impact on whether you have a legitimate work comp claim. However, the simple fact that you have had some prior back problems, for example, does not necessarily disqualify you from bringing a claim for current back problems related to a work injury or your work activities. The issue is more complicated than that.

Example: Prior Back Problems

The real question is whether your prior back problems were affecting your ability to work or limiting your physical or other activities prior to the work incident. Many people have back problems or other physical ailments which intermittently give them some problems but “come and go”. They are able to continue working and enjoying their usual and regular physical activities with only occasional flareups of symptoms. If a work injury or your regular work activities significantly aggravates or accelerates a pre-existing condition to the point where you now need medical care and may need some physical restrictions or limitations, then you probably have a work comp claim.

Prior Work Comp Claims Involving the Same Body Part

Another common issue arises where a person has had a prior work comp claim involving the same body part. We’ll continue with the example of a bad back. Let’s say you had a back injury 10 years ago which was treated as work comp. The insurance company paid you wage loss and medical benefits but you were able to return to work. Now, you have had a new back injury or your work activities have gradually caused an increase or return of your back problems. The claim could be against the same or a new employer, but there will probably be a different work comp insurance company involved since your claim from 10 years ago.

This is a work comp claim, but you can almost be assured there will be a dispute between the current work comp insurance company and the company that provided coverage 10 years ago when you filed your prior claim. In all likelihood, the claim will be covered by one insurance company or the other, but there may be a delay in obtaining benefits while the insurance companies slug it out between themselves.

When in Doubt —  Contact an Attorney

If you find yourself in a situation where your claim has been denied because the insurance company says you have a pre-existing condition, or if two insurance companies are each arguing that the other is responsible, it’s time to contact an attorney. The insurance companies have lawyers and other experts protecting their interests and they are not looking out for yours. An experienced work comp attorney should be able to review your medical records and any prior work comp records and give you an opinion as to what type of claim you have. If the insurance company wants to fight, make sure you have an attorney who is willing to go to bat for you and get you the benefits to which you are entitled.

At Bradt Law Offices, we have been representing your friends and neighbors in work comp and other injury claims for over 30 years. Our clients come from all over northern Minnesota and we are happy to discuss any claim, with anyone, at any time. Whether you just have some questions over the phone or would like to make an appointment to come in for a free consultation, don’t hesitate to call and let us help you. You will always get our honest opinion and there is never any fee unless we recover benefits for you.

Thank you for visiting our blog.