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What about medical bills when a Wisconsin workers' comp claim is denied?

In Wisconsin, as in other states, the workers' compensation system provides that an employer or its insurance carrier is responsible for medical bills when an employee is injured at work or contracts a work-related disease. Wisconsin law requires that medical treatment for work injuries and illnesses must be covered by workers' comp if the treatment is necessary for the particular work-related medical problem.

This system generally works well when a claim for workers' comp benefits is promptly approved and liability on the part of the employer is clear. In this scenario, medical bills should be paid within a reasonable time directly by the employer's workers' compensation insurer.

Covered medical treatment

Medical expenses are broadly covered by workers' compensation and can include physician and hospital services, prescribed medication, physical and occupational therapy, chiropractic care, dental services, medical supplies and equipment, diagnostic and laboratory tests, mental health treatment, mileage for travel to these services, and more.

Often overlooked but vitally important, even after an injured or ill worker reaches maximum improvement, medical expenses to keep him or her at that level of health and to prevent deterioration should also be covered by the workers' compensation claim. Despite this legal provision, many claims for ongoing medical treatment are wrongfully denied after the worker reaches a healing plateau.

Denied or delayed claims

Unfortunately, if an injured or sick worker's claim is denied and he or she must appeal the denial, medical bills can start to pile up until the claim is resolved, especially if the worker does not have health insurance to cover them. If the health insurer does pay these bills and the claim is later approved, the health insurer should get reimbursement from the liable employer or its insurer.

The same is true for bills paid by the worker that are ultimately found to be covered by workers' comp; the worker should be repaid.

A worker in this situation - unable to work and without his or her paycheck - may be out of the cash necessary to pay those medical expenses and face attempts from medical providers to collect the debts. This financial pressure can be extremely stressful for an already injured or sick person trying to recover medically.

Learn about options from legal counsel

A person with pending medical bills related to a denied workers' comp claim in Wisconsin should speak with an experienced workers' compensation lawyer about what options and legal remedies might be available to alleviate the situation. Here are some possible actions to take:

  • Appeal the denied claim, including presenting the case at an administrative hearing through the Worker's Compensation Department.
  • Use personal health insurance and later bring a claim for reimbursement to the group health carrier and to the worker for any co-pays and out-of-pocket expenses.
  • Negotiate with the employer's workers' comp insurance company about responsibility for the bills.
  • Apply for public medical assistance through the state of Wisconsin.
  • Attempt to get medical coverage through the health care exchanges ("ObamaCare") that will take effect in 2014.
  • File a claim with the Workers' Compensation Department to request a judge order that the employer's workers' compensation insurance carrier pay for prospective medical treatment that is related to a work-related illness or injury. This would prevent the future treatment from being billed to the worker.

These potential alternatives are often legally and procedurally complex and should be thoroughly discussed with a knowledgeable workers' comp lawyer to understand the pros and cons of each, as well as the steps to take.

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