A common occurrence in a New York Workers’ Compensation claim is for an injured worker to have treatment denied by the insurance company. There are a number of reasons that this can happen. One reason may be that the case is being challenged by the insurance carrier. This situation generally gets resolved by litigation and depends on whether the law judge establishes a case.
Once a case gets established, an injured worker is entitled to causally related, medically necessary treatment. An insurance carrier may deny treatment that is not for one of the established sites of injury. For instance, if I have a case that is for a back injury and I try to get treatment for my knee, the insurance carrier will deny the payment of the medical bill. Sometimes, consequential injuries may arise and would require a case to be amended to include the new injury site.
The most common reason that treatment can be denied is because the insurance carrier obtains an opinion from their own medical consultant or independent medical examiner (IME) that states that treatment being requested is not medically necessary or not recommended by the medical treatment guidelines. When treatment gets denied under these circumstances it can be both frustrating and confusing on how to navigate the process to get approval. The process generally involves getting a hearing scheduled for a judge to rule on the treatment authorization and in some instances litigation is required.
The attorneys at MCV Law excel at navigating the often complex and trying process of getting treatment authorized for our clients.