What Can You Do When Workers’ Compensation Refuses Treatment?
By the Law Offices of Michael S. Williams, LLC
After suffering an injury at work, you may expect your employer’s workers’ compensation insurance carrier to provide the medical treatment necessary for you to recover. Unfortunately, even when a carrier accepts a workers’ compensation claim, disputes can arise over the type and extent of treatment it will authorize.
The insurance carrier may refuse to approve an MRI, specialist evaluation, physical therapy, injections, surgery or treatment for an additional injured body part. An authorized doctor may also discharge you from treatment or release you to return to work even though you continue to experience significant symptoms.
A refusal by the insurance carrier does not necessarily end the issue. New Jersey workers’ compensation law provides procedures through which an injured employee can seek appropriate medical treatment and temporary disability benefits.
Who Controls Medical Treatment in a New Jersey Workers’ Compensation Case?
In New Jersey, the employer or its workers’ compensation insurance carrier generally has the right to select the doctors and other healthcare providers authorized to treat a workplace injury.
This means that an injured employee ordinarily cannot select any doctor, obtain treatment and automatically require the workers’ compensation carrier to pay the bill. Except in an emergency or certain other circumstances, treatment from an unauthorized provider may result in a dispute over responsibility for the expense.
However, the carrier’s right to select authorized medical providers does not give it an unlimited right to deny necessary treatment. The employer remains responsible for providing authorized treatment that is reasonably necessary to cure or relieve the effects of a compensable work injury.
You can learn more about the selection of medical providers in our article: Can You Choose Your Own Doctor in a New Jersey Workers’ Compensation Case?
What Types of Workers’ Compensation Treatment Are Commonly Denied?
A workers’ compensation carrier may authorize some treatment but refuse to approve the next step recommended by the authorized doctor.
Disputes commonly involve requests for:
• An MRI, CT scan or other diagnostic testing
• Evaluation by an orthopedic surgeon, neurologist or other specialist
• Physical therapy
• Chiropractic treatment
• Pain-management treatment
• Epidural or other therapeutic injections
• Surgery
• Prescription medication
• Medical equipment
• Transportation to authorized appointments
• Treatment for another injured body part
• A second medical opinion
• Additional treatment after an authorized doctor attempts to discharge the employee
The carrier may contend that the requested treatment is unnecessary, unrelated to the workplace accident or unlikely to improve the employee’s condition. It may also rely upon an examination performed by another physician who concludes that no further treatment is required.
These disputes frequently require a careful review of the authorized treating physician’s recommendations, diagnostic studies, prior medical history and the employee’s continuing complaints and physical limitations.
What if the Carrier Accepts the Claim but Denies Additional Treatment?
Acceptance of the initial workers’ compensation claim does not guarantee that every future treatment recommendation will be approved.
For example, a carrier may authorize an emergency-room evaluation and several weeks of physical therapy but later refuse to approve an MRI. It may authorize an orthopedic evaluation but deny the specialist’s request for injections or surgery. It may accept an injury to one body part while denying that another condition arose from the same accident.
An employee does not necessarily have to accept the carrier’s denial as the final decision. Depending upon the medical evidence, the employee may be able to request court intervention.
Can You Request a Second Medical Opinion?
An injured employee may ask the carrier to authorize an evaluation by another physician when there is a legitimate dispute concerning the diagnosis, treatment or decision to discharge the employee.
The carrier is not always required to voluntarily grant that request. If it refuses, the employee and the employee’s attorney can evaluate whether sufficient medical and factual support exists to seek additional treatment through the Workers’ Compensation Court.
A request for another opinion may be particularly important when:
• The authorized doctor has not addressed all injured body parts
• The employee’s symptoms continue to worsen
• Diagnostic testing reveals significant findings
• Recommended treatment has not improved the employee’s condition
• The doctor releases the employee despite continuing physical limitations
• Surgery is recommended and the employee reasonably wants another evaluation
• Different authorized physicians provide conflicting opinions
Whether a second opinion should be pursued depends upon the circumstances of the particular claim.
What if the Authorized Doctor Discharges You Too Soon?
An authorized physician may conclude that the employee has reached maximum medical improvement, commonly called MMI. This generally means that the physician believes additional treatment will not materially improve the work-related condition.
A finding of MMI affects both medical treatment and temporary disability benefits. The carrier will use the doctor’s report to terminate treatment and stop temporary disability payments.
However, an injured worker may disagree with the physician’s conclusions. The employee may still have substantial pain, physical limitations or unresolved symptoms. Another authorized physician may have recommended additional testing or treatment that was never completed.
When this occurs, an attorney can review:
• The authorized treatment records
• Diagnostic test results
• Outstanding treatment recommendations
• The employee’s current symptoms and limitations
• Whether all injured body parts were evaluated
• Whether the employee can perform the physical requirements of the job
• Whether additional medical evidence supports continued treatment
If the evidence supports further care, the employee can challenge the discharge and seek additional treatment through the Workers’ Compensation Court.
What if the Doctor Sends You Back to Work Before You Are Ready?
A doctor’s return-to-work determination can directly affect an employee’s right to temporary disability benefits.
An authorized physician may release an employee to full duty or impose light-duty restrictions. Work restrictions do not always mean temporary disability benefits stop. If restrictions cannot be accomodated by the employer, temporary disability benefits should continue.
The employee should not simply ignore the release or fail to report to work without obtaining legal advice. An unexplained refusal to return can create additional problems in the workers’ compensation case and with the employment relationship.
Instead, the employee should promptly document:
• Continuing symptoms
• Physical activities that cannot be performed
• The actual requirements of the job
• Written work restrictions
• Communications with the employer
• Whether suitable light-duty work was offered
• Any unsuccessful attempt to return to work
An attorney can evaluate whether additional medical treatment, modified restrictions or continued temporary disability benefits should be pursued.
What Is a Motion for Medical and Temporary Benefits?
When appropriate medical treatment or temporary disability benefits are denied, an injured employee may be able to file a Motion for Medical and Temporary Benefits with the New Jersey Division of Workers’ Compensation.
The motion can ask a Judge of Compensation to order the employer or its insurance carrier to provide medical treatment, temporary disability benefits or both.
According to the New Jersey Department of Labor and Workforce Development, a Motion for Medical and Temporary Benefits provides recourse to an injured worker who needs prompt treatment or temporary benefits. The motion is assigned an initial hearing date before a Judge of Compensation within 30 days after filing.
The motion must be supported by medical evidence. Depending upon the dispute, that evidence may include:
• Reports from the authorized treating physician
• Medical records documenting continuing symptoms
• Diagnostic studies
• Treatment recommendations
• Work-status notes
• Reports from another examining physician
• A certification from the injured employee
• Evidence concerning unpaid temporary disability benefits
The employer and insurance carrier have an opportunity to respond and present their own medical and factual evidence. The court may conduct conferences, receive testimony or otherwise address the dispute under the applicable workers’ compensation procedures.
Can the Court Order the Insurance Carrier to Provide Treatment?
Absolutely. A Judge of Compensation can decide disputes concerning the nature and extent of medical treatment owed for a compensable workplace injury.
The injured employee must generally establish that the requested treatment is related to the work injury and medically necessary. The employer or carrier may dispute causation, the need for treatment or whether additional care is likely to cure or relieve the condition.
The outcome depends upon the medical evidence and specific facts of the claim. Filing a motion does not guarantee that the requested treatment will be ordered, but it provides a method for presenting the dispute to the court instead of allowing the carrier to make the final decision without review.
Can You Obtain Temporary Disability Benefits While Treatment Is Disputed?
Temporary disability benefits may be available when a compensable workplace injury prevents an employee from working and the employee remains under active medical care.
These benefits are generally calculated at 70% of the employee’s average weekly wage, subject to New Jersey’s statutory minimum and maximum rates.
Disputes may arise when:
• The carrier refuses to begin temporary disability payments
• The weekly benefit rate is incorrectly calculated
• Payments are delayed or missed
• Benefits stop after a premature return-to-work release
• The employee remains unable to work while treatment is disputed
• The employer offers work that does not comply with medical restrictions
A Motion for Medical and Temporary Benefits may seek both necessary treatment and the payment or reinstatement of temporary disability benefits. Eligibility depends upon the medical evidence, the employee’s ability to work and the circumstances surrounding the termination or denial.
What Should You Do When Treatment Is Denied?
An injured worker should not wait for the insurance carrier to deny treatment or the claim before speaking with a workers’ compensation attorney.
In fact, an injured worker should consult an experienced workers’ compensation attorney as soon as possible after a workplace injury even when the employer has accepted the claim and started providing medical treatment.
Insurance carriers control authorized medical treatment in New Jersey, and important disputes can develop long before a formal denial is issued. A carrier may accept the accident but later dispute:
• Treatment for an additional injured body part
• An MRI or other diagnostic testing
• A referral to a specialist
• Physical therapy, injections or surgery
• A request for a second medical opinion
• Continued treatment after an authorized doctor attempts to discharge the employee
• The employee’s inability to return to work
• The correct amount or duration of temporary disability benefits
Early legal representation can help ensure that the accident and all injured body parts are properly reported, treatment requests are documented, temporary disability benefits are correctly calculated and inappropriate treatment decisions are promptly challenged.
Waiting until treatment has stopped, benefits have been terminated or the employee has been released to work can make the dispute more difficult. An attorney can monitor the claim from the beginning, address problems as they arise and seek court intervention when necessary.
Even if your employer and its insurance carrier initially appear cooperative, their interests are not the same as yours. You should not wait for something to go wrong. Have an attorney protect your rights throughout the workers’ compensation process.
How Long Do You Have to File a Workers’ Compensation Claim?
A formal New Jersey workers’ compensation Claim Petition generally must be filed within two years of the date of injury or the last payment of compensation, whichever is later. Employer-authorized medical treatment may qualify as a payment of compensation.
Different time-limit rules apply to certain occupational disease claims. An application for an informal hearing does not stop the two-year limitations period from running.
Because filing deadlines depend upon the facts of the claim, injured employees should not wait until the limitations period is about to expire before seeking legal advice.
Speak With a New Jersey Workers’ Compensation Lawyer
If your employer or its insurance carrier is refusing medical treatment, you do not have to accept that decision without review from the Workers’ Comp Court.
The Law Offices of Michael S. Williams, LLC represents injured workers in disputes involving:
• Denied or delayed medical treatment
• Refused diagnostic testing
• Denied specialist evaluations
• Refused injections or surgery
• Premature discharge from treatment
• Return-to-work disputes
• Stopped or unpaid temporary disability benefits
• Motions for Medical and Temporary Benefits
Attorney Michael S. Williams has represented injured New Jersey workers for nearly 20 years. Our firm regularly appears in the Freehold Workers’ Compensation Court and represents injured employees throughout Monmouth County, Middlesex County and across New Jersey.
Learn more about our workers’ compensation representation:
Monmouth County Workers’ Compensation Lawyer
Tinton Falls Workers’ Compensation Lawyer
Freehold Workers’ Compensation Lawyer
Call 732-351-2800 for a free consultation.
Our offices are located in Tinton Falls and New Brunswick. Telephone and virtual consultations are also available. There is no upfront attorney’s fee.
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Legal Disclaimer
This blog is provided by the Law Offices of Michael S. Williams for informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship. Every personal injury case is unique, and outcomes depend on the specific facts and applicable law. You should not act or refrain from acting based on the information contained in this blog without first consulting a qualified attorney licensed in New Jersey.
