When Injured On The Job, Workers’ Compensation

 Should Pay the Medical Bills

Recently, in my practice as a Worker’s Compensation attorney, it has come to my attention that workers, employers and even attorneys who do not regularly handle workers’ compensation cases do not understand the importance of promptly reporting work related injuries. Failure to report even a minor injury and seek appropriate authorization for medical treatment from the workers’ compensation insurance carrier can result in unpaid medical bills and mountains of red tape for injured workers trying to recover from their injuries.

Although there are a few rare exceptions, as a matter of practice New Jersey law requires all employers to carry workers’ compensation insurance that provides medical and other benefits to workers injured on the job regardless of how the injury occurred.

The problem usually begins when a worker who is injured on the job uses his family’s health insurance to cover medical bills that should be covered under his employer’s worker’s compensation insurance. A classic example is when a worker, believing he has suffered a minor but painful knee or ankle sprain seeks treatment from his family physician or chiropractor. When conservative treatment fails, the worker seeks treatment from a specialist who recommends expensive physical therapy or even surgery. This prompts the health insurance company to more closely scrutinize the workers’ claim. When the health insurance company determines that the need for treatment is related to the claimant’s work, all further treatment is denied because of an exclusion in the health insurance policy that prohibits coverage for work related injuries. Even worse, the health insurance company may deny coverage for medical treatment already rendered, leaving the injured worker personally responsible for hefty medical bills. When the injured worker, now desperately in need of treatment, looks to his employer’s Worker’s Compensation insurance, he is met with a great deal of skepticism because the work related injury was not promptly reported to the Worker’s Compensation insurance carrier.

With more and more frequency, I am being told by my clients that they used their health insurance for work related medical bills because they did not want to bring a worker’s compensation case against their employers. A client will often say to me, “I didn’t think it mattered which insurance company paid the bills, as long as the bills got paid.” Unfortunately, it does matter which insurance company pays the bills and it is important that a workers’ compensation case is treated as such from the very beginning.

The worker then had no alternative but to seek the advice of a Worker’s Compensation attorney.

When the worker came to see me, I advised him that there were legal remedies to help his situation, but that legal action could take a considerable amount of time. In the meantime, he was unable to work and unable to obtain medical treatment for his injury either from his health insurance company or the Worker’s Compensation carrier.

The lawyer who finds his client in such a situation must take the following measures. First, the lawyer must obtain the client’s medical records as well as an narrative report from a physician who is willing to testify that the need for treatment is related to a work related injury. After obtaining these records and the narrative opinion, the lawyer should file a motion for medical and temporary disability benefits.

Court rules require that such a motion be heard within thirty-five days. However, as a practical matter, a decision could take considerably longer and may not be completely in the injured worker’s favor.

Regarding the injured worker’s case, a Judge of Worker’s Compensation could find that the worker did injure his knee at work and is therefore entitled to future medical treatment and temporary lost wages from the employer’s Worker’s Compensation carrier.

However, a Judge could also determine that the initial orthopedic treatment, physical therapy and MRI were unauthorized and therefore not covered under Worker’s Compensation. The Worker’s Compensation Statute requires an injured worker to obtain authorization from the Worker’s Compensation insurance company before receiving medical treatment. The injured worker and his lawyer may now find themselves arguing with the health insurance company to cover the bills that were not authorized and covered by Worker’s Compensation insurance.

Once a Judge of compensation has determined that the worker suffered a work related injury, the worker is entitled to the following Worker’s Compensation benefits.

First, he is entitled to have his future medical bills paid 100% by the Worker’s Compensation carrier. However, as stated above, only such treatment as is authorized by the Worker’s Compensation carrier will be paid for by the Worker’s Compensation carrier.

Second, the worker is entitled to 70% of his lost wages. However, again here there is a caveat. Lost wages can only be collected if the worker has been disabled for more than seven consecutive days. The worker is only entitled to these lost wages while an authorized treating physician has determined he is unable to work due to the work related injury. The maximum rate a worker can receive is just 75% of the state average weekly wage (SAWW). Thus, for example, a worker injured in 2009 earning $1,500.00/week gross earning will only receive $773.00.

Finally, twenty-six weeks after treatment is complete, the worker will go for exams to determine whether there is some permanent disability from the work related injury. If it is determined that the worker suffered a permanent injury, he will be paid such permanent disability pursuant to the Worker’s Compensation Statute.

In conclusion, failing to report a work related injury could result in the worker being responsible for his own medical bills. It can also compromise the worker’s right to lost wages and a forfeiture of permanent disability benefits. Many workers fear retaliation from their employer if they seek Worker’s Compensation benefits. However, New Jersey Law is clear that an employer cannot fire or discriminate against an employee for seeking Worker’s Compensation benefits. It is important that work related injuries be handled as such from the very beginning.