If you file a worker’s compensation claim, and it’s accepted by the insurance carrier, all treatment and related expenses for that injury will be covered. More specifically, the treatment and expenses for the accepted “body part” will be covered. What’s the difference? A lot in terms of getting things authorized and paid for by the insurance company.
To fully understand the difference, let’s back up to the day when you were injured and went to seek medical attention. During that initial visit with the doctor, you explained your injury and what happened. The doctor, in turn, wrote a “First Report of Injury” (FROI). In that report, the doctor lists which body parts were injured.
So for instance, let’s say that you picked up a box at work and felt a pain in your left shoulder. When you went to the doctor, you explained that you feel pain in the left shoulder area. The doctor then listed the affected body part as “left shoulder” and all of your treatments (testing, therapy, etc) will be focused on your left shoulder only.
Now let’s say that a few days/weeks later, you also feel pain in your left neck area. You report the left neck pain to your doctor and assume that you will receive treatments for your neck pain as well as your shoulder pain. Wrong! The insurance company could, and may, deny the neck as an accepted body part because it was not listed on the doctor’s FROI. Therefore, they will not authorize any treatments related to the neck area. This is why I stated that all treatment and expenses will only be covered for accepted “body parts” rather than accepted “injuries”.
Getting a denied “body part” to be accepted under a claim is tricky and complicated. This is why many injured workers hire attorneys. However, hiring an attorney is not always the best solution to the problem. Before hiring an attorney, I suggest that you speak directly with your adjuster and explain why you feel that the denied body part should be accepted with your claim. Many times, having this simple conversation can clear up the confusion regarding what was injured during your accident. Also, if you have a Nurse Case Manager, she could act as your advocate and speak with the adjuster to decide which body parts should be included in the claim. Hiring an attorney should be your last resort, not your first option.
In addition to paying for the needed treatments, the insurance company will pay for the expenses associated with your claim. Your mileage, parking, and some out-of-pocket expenses are all reimbursable if you submit an expense form to the adjuster. So keep track of your mileage and parking fees when going to your doctor and therapy appointments. Also, save the receipts for out-of-pocket expenses like over-the-counter medications, ice packs, bandages, etc. that are required for your recovery. If you can’t afford transportation or upfront out-of-pocket expenses, you can also request that these things are provided for you and paid for by the insurance company.
Lastly, the insurance company will pay you a percentage of your salary if the doctor states that you are unable to work or if your employer cannot accommodate your work restrictions. This compensation is generally only 2/3rds of your regular salary. But getting something is better than nothing.
Lolita Korneagay, RN, BSN, MBA, ALNC is a Registered Nurse and Patient Advocate that has over a decade of experience with assisting patients recovery from illness and injuries. She provides expert medical consulting to patients, employers, insurance companies, and attorneys regarding healthcare claims. For a consultation, visit www.korneagaylnc.com for additional information.