What Can I Do if I am Unhappy with the Medical Care I am Receiving from my Worker’s Compensation Doctor?One of the biggest areas of dispute in the Georgia workers’ compensation system arises from the medical care provided by the insurance company as part of its claim management. I regularly speak with clients and prospective clients who express a great deal of frustration and unhappiness about what they consider to be sub-par care.
While it would be nice to believe that every medical doctor truly has his patient’s best interests at heart and wants to provide only the highest quality of medical care, the truth is that the quality of medical care provided under workers’ compensation does not meet such a high standard. Like any other third party payment system, workers’ comp in Georgia requires physicians to fill out many forms and the payment schedule for various services is set out in the statute.
As a result, not every Georgia physician will accept workers’ compensation payments. At the same time, other physicians work in clinics that exist primarily to treat injured workers. The owners of these “industrial clinics” are willing to trade lower reimbursement rates for the certainty of a regular flow of business and one type of payment processing. Because industrial clinic physicians earn their livelihood from insurance company referrals, they tend to offer very conservative diagnoses and they avoid sending patients out for expensive diagnostic tests or expensive treatment.
Your Options for Seeking Better Medical Care
One Free Switch to Another Panel Physician
Under the Georgia workers’ compensation law, if the insurance company has accepted the claim as a compensable injury, has a valid posted panel of physicians and has met the other requirements of the posted panel statute, you as the injured worker must choose a physician from that posted panel. If you are not happy with your treatment, the law provides that you have a one-time option to switch to another panel physician.
Claimant’s Independent Medical Exam
If you are receiving income benefits, Georgia law allows you to demand an independent medical exam with a physician of your choice, paid for by the insurance company. This “claimant’s IME” is something that I use to contest an effort by the employer to terminate benefits or to support a formal request for a change in treating physicians.
File a Request for Change in Treating Physicians
If you have been under the care of a panel physician and your condition is not improving, or if the claimant’s IME suggests that your panel physician is not properly addressing your medical problems, we can file State Board Form WC-200(b) requesting a change in treating physicians. Often I can negotiate a change with the insurance adjustor but sometimes this issue must be heard by a judge or a mediator.
Medical Treatment When Claim has been Denied by Insurance Company
If the insurance company denies your claim, it cannot control where you obtain medical treatment. You can go to any physician you choose and if you later prevail at a hearing, the insurance company will have to pick up the tab for all related medical care.
Obviously there is a risk to this – if you have no other insurance and you run up thousands of dollars of medical expenses, you will be expected to pay the bill.
As a practical matter, if you have a serious injury and the insurance company denies your claim, they will make an offer to settle on a “no liability” basis, meaning that they will pay a lump sum but will not admit that your injury arose out of or in the course of employment. In such a scenario, your outstanding medical bills will have to be paid out of the proceeds of your settlement.
Medical Care Options – Summary
As you can see, you do have several options with regard to medical care in your workers’ compensation case. I hope you can also see that these options require thoughtful consideration and perspective, which is what I can offer you as your legal counsel. If you are not satisfied with the quality of treatment you are receiving, please fill out the form on the right side of this page to contact me.