Reasons for Denials of Medical Benefits in Louisiana Workers Compensation

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In Louisiana workers compensation, an injured employee is entitled to have all of his or her accident-related medical bills and expenses paid by the employer's workers compensation insurance company.

These medical bills include all necessary and reasonable medical expenses pertaining to the work-related injury, such as:

    • Doctors visits; 
    • Diagnostic tests such as X-rays and MRIs;
    • Medical treatments;
    • Surgeries and surgical treatment;
    • Prescription drug medications;
    • Medical supplies;
    • Hospital care and stays;
    • Bloodwork and lab tests;
    • Medical tests;
    • Physical therapy;
    • Medical rehabilitation efforts required for physical recovery;
    • Prosthetic devices;
    • Medically necessary treatments recommended by the treating physician;
    • Reasonable travel expenses for obtaining medical services, medicines, and prosthetic devices; and
    • Any non-medical treatment recognized by the laws of Louisiana as legal and related to the work injury.

In fact, Louisiana workers compensation provides medical treatment guidelines that detail what comprises reasonable and necessary medical treatment, as well as a medical fee schedule to set the costs of specific medical care and treatments.

Also, except for emergency care, the workers compensation insurance company must approve in advance any treatment that costs over $750.00.

The Insurance Companies Frequently Deny Medical Treatment in Louisiana Workers Compensation

Unfortunately, Louisiana workers compensation insurance companies love to deny medical treatment to injured workers.

As horrible as it is, the best strategy for these workers compensation insurance companies' financial bottom lines is to delay and deny medical treatment.

In fact, in order to discourage injured employees from receiving full medical treatment, these workers compensation insurance companies have devised the complicated Utilization Review process.

Some insurance companies perform longer investigations for more expensive treatments, like hospitalizations and surgeries, and other just outright deny certain claims no matter what.

So these workers compensation insurance companies have made the process for approving medical so complicated and difficult, in the hopes that:

    • Employees will give up on getting the full treatment they deserve;
    • Medical providers will seek approval for less than what the employee deserves; and
    • Attorneys, employees, and medical providers will not challenge the insurance companies on their denials.

In fact, the only way to ensure that an injured employee is receiving the full medical care he or she deserves, is for the employee to work with an attorney and a doctor who understand the complicated workers compensation Utilization Review process, and are willing to fight to get the full medical care that the injured employee deserves.

Reasons Why Medical Benefits May Be Denied in Louisiana Workers Compensation

The medical benefits due to injured employees are regularly and wrongly denied. 

In fact, a primary tactic of most workers compensation insurance companies is to deny, deny, deny.  

Typical reasons that the workers compensation insurance companies deny medical benefits in particular, include the following: 

    1. The workers compensation insurer claims that there is insufficient supporting medical documentation. When a medical provider requests approval for medical treatment over $750, the medical provider must provide supporting medical documentation to justify the treatment. However, this issue of insufficient supporting medical documentation can be easily remedied by providing the full and proper supporting medical documentation. It certainly helps to have a medical provider experienced in solving such issues. An experienced workers compensation attorney can find such a medical provider for an injured employee.

    2. The employee's request for workers compensation benefits may be denied for technical reasons. The Utilization Review process used to approve medical treatment over $750 is complicated, and it was designed by the insurance companies to be that way, so that they could routinely deny medical treatment. Nevertheless, this issue can be easily remedied by resolving any technical issues. A knowledgeable medical provider can fix such issues, but so can an experienced workers compensation attorney.

    3. The employee's medical condition does not fall under the Medical Treatment Guidelines. Certain treatments may not be covered for certain reasons under Louisiana's Medical Treatment Guidelines. But also, the workers compensation insurer may claim that a certain treatment is not covered under Louisiana's Medical Treatment Guidelines, when in fact it is. Really, only experienced workers compensation attorney willing to fight for an injured employee can handle such a dispute.

    4. The employee refused to sign medical authorizations. The workers compensation insurers are entitled to receive the employee's medical records, and thus in general employees are generally required to sign medical authorizations that will allow the insurer to request the medical records directly from the employee's health care providers. However, sometimes the insurer's medical authorizations can go overboard and invade the employee's privacy by seeking medical records that do not relate to the work accident.

    5. The workers compensation insurance company claims that the requested medical treatment is not "necessary." Louisiana law does require that the employee's medical treatment be reasonable and necessary. But often the insurance company's idea of "necessary" is just plain wrong. The insurance company may claim that there is a "less costly" way to treat the employee's injuries, despite the fact that the employee's treating physician - a medical doctor - is recommending such treatment. Typically, such a dispute will need to go through the Utilization Review process, and is best handled by an experienced workers compensation attorney.

    6. The workers compensation insurance company claims that the employee's injury is a pre-existing condition, or caused by a pre-existing condition that was not aggravated by a work-place injury. This is a typical scenario, where the insurance company tells the injured worker that because the worker has had ongoing back problems in the past, that it will not cover medical treatment for the employee's back after a workplace injury. This is not necessarily true. In Louisiana, if an injury at work aggravates a pre-existing injury, then the treatment for this injury must be covered by workers compensation.

    7. The insurance company claims that the employee can return to work safely and that he or she no longer need medical care at all. This situation occurs frequently when the injured employee uses the insurance company's doctor as the employee's treating physician. An injured employee should always select the employee's own doctor - and never use the insurance company's doctor - and preferably have an experienced workers compensation attorney help to select the employee's treating physician, before it is too late. 

    8. The employer or its workers compensation insurance company made a mistake. Sometimes people just make mistakes. Other times, people say they just made a mistake, when the mistake is actually the company policy. It is critical to identify the mistake and resolve it as soon as possible. And having an experienced workers compensation attorney can send a message to the insurance company that "mistakes" will not be tolerated.

    9. The workers compensation insurance company claims that the injury is not work-related. Workers compensation insurers frequently claim that "the employee's medical condition is not actually a result of a workplace accident." Unfortunately, the only way to handle such a dispute is to fight back by gathering the appropriate evidence to support the claim, and presenting it to the workers compensation in a proper fashion. This evidence could be witness testimony of co-workers, or a doctor's testimony, or medical records. Or it could be a proper legal argument presented to the workers compensation Judge. Either way, really the employee's only chance for success against the insurance companies' attorneys is to hire an experienced workers compensation attorney who is willing to fight for the injured worker.

Typical reasons that the workers compensation insurance companies deny workers compensation benefits in general, include the following: 

    1. The employer never reported the injury to its workers compensation insurer. Once the employer is notified of the injured employee's injury, the employer has 10 days to notify its workers compensation insurance company.  In fact, the employer must file a form called the First Report of Injury or Illness with the insurance company within 10 days.  If the employer is self-insured, it must file the First Report of Injury or Illness with the Office of Workers Compensation.  Failure of the employer to notify the insurer or file a First Report of Injury or Illness will delay the employee's benefits.

    2. The employer did not report the injury to the workers compensation insurer within the proper time limit.  Failure of the employer to notify the insurer or file a First Report of Injury or Illness within 10 days will delay the employee's benefits.  However, it is not a valid excuse for a delayed payment.

    3. The employer does not have the required workers compensation insurance.  Despite the fact that all employers are required to have workers compensation insurance or be self-insured, some employers either let their coverage lapse, have improper coverage, or even just outright ignore their legal responsibilities and requirements.  If the employer does not have workers compensation insurance, it can and should be sued directly, not only for the workers comp benefits which the employee is typically entitled, but also for the penalties and attorneys fees due to the fact that it failed to maintain the required workers compensation insurance.  Typically, if the employer does not have the proper insurance, then it does not understand the proper way to handle a claim, including when and how payments must begin.  

    4. The workers compensation insurer's claim file got misplaced or forgotten.  Workers compensation insurance companies often claim that they lost a file, or misplaced claim file, or forgot about it.  Whether these excuses are true or not is irrelevant. Again, indemnity benefits should be paid no later than the fourteenth day after the employer or their insurance company is notified of the employee's injury.  

    5. The workers compensation insurer is still processing the claim.  Workers compensation insurance companies love to remark that they are "processing" an injured employee's claim.  But again, this is no excuse.  Lost wage benefits should be paid no later than the fourteenth day after the employer or their insurance company is notified of the employee's injury.  

    6. The workers compensation insurer is conducting an investigation of the claim.  The workers compensation insurance company often claim that it has not issued a payment due to the fact that it is "investigating" the claim of an injured employee.  Typically, this means witness statements, medical records, and employment records.  Like its explanation of claim "processing," this is not a valid excuse. The insurer can investigate all it  wants, but it must issue the payment within 14 days of notification unless there is a valid reason otherwise.

    7. The workers compensation insurer denied the claim, but the employee was not notified about the denial.  Sometimes, an injured employee is simply not notified of a claim denial.  This is typically the fault of the insurer.  However, such an error is important, and must be handled appropriately by the employee or the employee's legal representative, since the employee will want to maintain all legal rights to file an appeal of a claim denial.

    8. The employee missed the deadline for filing a claim. Under Louisiana law, the employee must report his or her injury to the employer within 30 days.  Though in practice, a good attorney can get around this deadline, an employee should report the injury right away.  Otherwise, the insurer will likely delay or deny the claim, especially if it was reported over 30 days after the injury.  Also, at the time the injury is reported to the employer, the employee should request from the employer some written proof that the injury was in fact reported, such as a written accident report or injury report or simply an email.

    9. The employee failed to file an Employee's Monthly Report of Earnings.  When an injured worker in Louisiana is entitled to Supplemental Earnings Benefits (SEBs), the worker must file every month a Form 1020 - Employee's Monthly Report of Earnings.  The purpose of this Form 1020 is to report to the insurance company whether the employee had income during the month, so that the insurer can reduce indemnity by that amount.  The insurance company will typically delay any indemnity payments until it receives a completed Form 1020 each month.

    10. The employee filed the claim after leaving the job. Workers compensation insurers will typically deny claims that were filed after the employee was fired, laid off, or quit. However, just because the claim was filed after the employee was fired, laid off, or quit, does not mean that the injured employee is not entitled to workers compensation benefits. If the worker was injured in the course and scope of the worker's employment, then the injured worker is entitled to workers compensation benefits, regardless if the claim was made after the employee left the job. 

    11. The employee's initial medical records indicate the presence of illegal drugs. If an employee's medical records show illegal drugs in the employee's system soon-after a work-related accident, the workers compensation insurer is almost definitely going to deny workers compensation benefits on the basis of the failed drug test. However, a failed drug test does not disqualify an employee workers compensation benefits, it only creates a presumption against the employee. Often, an experienced workers compensation attorney can overcome this presumption and get the workers compensation benefits awarded to the employee. Plus, if the drug test was not pursuant to a written promulgated drug testing policy, than the drug test results will be inadmissible, and thus unusable as a basis to deny workers compensation benefits to the employee.

Penalties and Attorneys Fees in Louisiana Workers Compensation

If an injured employee's benefits are delayed or denied, the employee may ultimately file a claim with the Office of Workers Compensation.  The claim is initiated by filing a Form 1008 - Disputed Claim for Compensation.  

Within this Disputed Claim for Compensation, the injured employee may request penalties and attorneys fees in addition to regular workers compensation benefits.

Under Louisiana law, the employer or the workers compensation insurer will not owe penalties and attorneys fees "if the claim is reasonably controverted or if such nonpayment results from conditions over which the employer or insurer had no control."

Does the Insurance Company Have A Valid Reason for Its Denial of Benefits?

Additionally, if the employer or the workers compensation insurance company stops paying indemnity benefits without a valid reason, then the injured employee may be entitled to penalties and attorneys fees in addition to the regular workers compensation benefits.

Specifically, according to Louisiana law, "Any employer or insurer who at any time discontinues payment of claims due and arising under this Chapter, when such discontinuance is found to be arbitrary, capricious, or without probable cause, shall be subject to the payment of a penalty not to exceed eight thousand dollars and a reasonable attorney fee for the prosecution and collection of such claims."  

The critical determining factor here as to whether penalties and attorneys fees are appropriate, is whether the insurance company's actions were "arbitrary, capricious and without probable cause."  

In other words, did the insurance company have a good reason to deny the payments?  All too often, the answer is NO.

When to Get an Attorney in Louisiana Workers Compensation

Sadly, most injured employees wait too long before hiring an attorney.

It is never a good idea for an injured employee to wait until he or she "needs" an attorney, as by that time, the employee's rights have likely already been reduced, and the employee's claim value already diminished.

During the time before an employee hires an attorney, the insurance company is likely devaluing the employee's claim, and on the road to denial by stripping away the rights of the injured employee.  

For example, besides simply delaying an employee's claim, the insurance company will:

    1. Send the employee to the doctor of its choice, not of the employee's choice, which can produce medical records that can drastically limit or eliminate the claim;
    2. Unfairly limit or deny appropriate medical care, often causing permanent negative health and legal effects;
    3. Improperly calculate the amount of indemnity payments due the employee;
    4. Wrongly force or pressure the employee to return to work, which will eliminate indemnity payments and limit medical care going forward;
    5. Insist upon inappropriate vocational rehabilitation, which can irreversibly eliminate indemnity payments to the employee;
    6. Pressure an injured employee into a low-ball settlement, by leveraging against the employee the present financial and medical stress of the employee; and
    7. Falsely claim that its settlement offer is a take-it-or-leave-it offer, even though it is never a take-it-or-leave-it offer.

In short, if an injured employee is not represented by a skilled Louisiana workers compensation attorney, then the employee is not effectively protected by the Louisiana workers compensation laws.

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