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How is medical care handled in a workers' compensation claim?

A San Jose worker who is injured on the job or suffers a condition from the type of work he or she does and cannot work will need to consider workers' compensation. One integral aspect of workers' compensation benefits is medical care. There are frequently concerns as to who pays for it, what treatment is available, and if there are any limits on the type of treatment that can be received. Knowing the details of these factors can help a worker who is not receiving the medical care he or she is supposed to or if an employer is not paying the medical expenses as required under the law.

The employer is required to pay for medical care for a worker who was injured or became ill on the job. This is through workers' compensation insurance or self-insurance. The claims administrator will pay the bills. The worker should not receive any bills provided the claim was filed and the doctor knows that the issue stemmed from work. The doctor cannot bill a worker as a matter of law. Medical care after a workplace injury or illness is supposed to "cure or relieve" the effects of the injury. The guidelines doctors will follow in the state are based on the medical treatment utilization schedule (MTUS). This is a publication from the Division of Workers' Compensation (DWC). There are multiple guidelines in the MTUS and it is meant to help a doctor give the correct treatment based on the worker's issues.

A doctor might recommend treatment that is not in the guidelines. If that is the case, the claims administrator must pay for the treatment if it is based on science. If a case has been settled with an agreement on medical care the person needs in the future, the treatment must be paid for by the administrator. There are certain limits on chiropractic treatment, physical therapy and occupational therapy. Those whose injuries occurred in 2004 or later will get 24 visits for each. The claims administrator can allow more and this must be in writing.

With workers' compensation claims, the worker must be knowledgeable about what the employer and the insurer are required to do in terms of treatment and medical care. If there is a problem with any medical treatment that is to be provided via workers' compensation, having a lawyer who is experienced in these matters is one of the most important calls that a person can make.

Source: dir.ca.gov, "Workers' Compensation in California -- A Guidebook for Injured Workers -- Chapter 3. Medical Care, pages 10-11," accessed on July 18, 2017

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