Workers Compensation

Workers Comp Medical Issues FAQ

By Sachi Barreiro, Attorney, University of San Francisco School of Law
Learn about medical treatment in workers' comp, including how to find a doctor, whether you can refuse treatment, and whether you have to accept light-duty work.

Q: What medical benefits are available through workers' comp?

  • A: Medical benefits are available through workers’ comp to pay for reasonable and necessary medical treatment. Workers’ comp will generally cover your bills for doctors’ visits, hospital stays, medication, and medical equipment you need for your work-related injuries. Other treatment, such as physical therapy, acupuncture, and chiropractic services, may also be covered. However, treatment that is considered experimental or unnecessary will not be covered through workers’ comp.

    For information on the other types of benefits available through workers’ comp, see our FAQs on workers’ comp benefits.

Q: How long will it take for my medical benefits to begin?

  • A: Medical benefits are available once your employer’s insurance company accepts your claim. The insurance company will pay your medical providers directly, so you shouldn’t be billed for your doctors’ visits and other medical appointments.

    In some states, your medical expenses will be covered while the insurance company is deciding whether to accept or deny your claim. For example, in California, you can receive up to $10,000 in medical coverage while the insurance company is investigating your claim. If your claim is accepted, workers’ comp will continue to pay for your medical treatment. And, even if your claim is denied, you usually won’t be responsible for reimbursing the insurance company for any of the medical bills it paid.

Q: How do I choose a doctor?

  • A: The rules for selecting a treating doctor are very different from state to state. In some states, such as Ohio, the employee may select any doctor that is on a list approved by the state workers’ compensation board. In other states, such as New Jersey, the employer has the right to select the treating doctor.

    In other states, the rules are more complicated. For example, in Pennsylvania, if the employer has a list of approved health care providers, the employee must see a doctor from the list for the first 90 days of treatment. After that time, the employee can select the physician. In California, an employee can receive treatment from his or her normal primary care physician, but only if the employee predesignated the physician before the work injury. Otherwise, the employee must typically see a doctor in the employer’s medical provider network.

    These rules don’t apply to emergency treatment. If you have an urgent medical issue, you may get treatment from the nearest doctor or emergency room.

Q: Does my employer have to honor my work restrictions?

  • A: Yes, your employer must honor any medical restrictions imposed by your treating doctor. Any light-duty work that your employer offers while you are recovering must take your medical restrictions into account. Your employer can’t ask you to perform work tasks that violate your doctor’s orders.

Q: Do I have to return to work before I've completely recovered?

  • A: If your doctor clears you to return to part-time or light-duty work, and your employer offers such work, you will probably have to accept it. If you refuse to accept the work, your workers’ comp benefits may be reduced or stopped altogether. However, if your pay for part-time or light-duty work is less than your regular earnings, you will still be eligible for temporary disability benefits to make up part of the difference.

Q: Can I refuse further treatment if I think it's causing more harm or isn't helping my condition?

  • A: Yes, you can always refuse to undergo medical treatment. However, an unreasonable refusal to accept medical treatment may mean the end of your workers’ comp benefits. Whether or not your refusal is reasonable depends on several factors, including how likely the treatment is to improve your condition and what risks are involved. If you feel that the treatment is doing more harm than good, discuss your concerns with your doctor before taking action. If your doctor isn’t responsive to your concerns, you may want to get a second opinion on whether the recommended treatment will improve your condition.

Q: What is an independent medical exam (IME)?

  • A: An independent medical examination (IME) is a medical evaluation performed by someone other than your treating doctor. An IME is usually requested by the insurance company when it disagrees with your treating doctor’s opinions about what treatment you need or the degree of your permanent disability. The insurance company selects and pays for the IME doctor who will examine you. After the exam, the IME doctor will issue a report about your condition, including the degree of any permanent disability you have and your ability to work in the future. As a result, the IME report can have a large impact on how much the insurance company decides to offer you for your workers’ comp claim. (For more information, see Tips for Handling Your Independent Medical Examination for Workers' Comp.)

Q: What can I do if my treating doctor doesn't agree with the IME report?

  • A: Both you and the insurance company are entitled to rely on the findings of your respective doctors. In fact, workers’ comp cases often involve disputes about which doctor's opinion is the correct one. If your treating doctor disagrees with the IME report, you can ask your doctor to write a letter to counter the IME report and use it as leverage in settlement negotiations. If you and the insurance company aren’t able to reach a settlement, your case will continue on to a hearing or trial.

Q: Does a nurse case manager have the right to go to my doctor's appointments?

  • A: In some cases, the insurance company will assign a nurse case manager to your workers' comp case. The nurse’s role is to act as an intermediary between the doctor and the insurance company, reporting on your progress and other issues related to your case. Although the nurse may appear to have your best interests in mind, you should remember that the nurse works for the insurance company. While some nurse case managers can be helpful in getting medical treatment authorized, others may be biased and advocate for your doctor to stop your treatment and return you to work before you’re ready.

    If you are assigned a nurse case manager, the nurse may attempt to sit in on your doctor’s appointments. In most cases, you can refuse to allow the nurse to sit in on your medical appointments. If you don’t want a nurse case manager, you can also typically ask the insurance company to remove the nurse from your case.

Q: What is a functional capacity evaluation (FCE)? How are the results used?

  • A: A functional capacity evaluation (FCE) is a test that is sometimes used to determine whether you have any physical restrictions that might impact your ability to work in the future. Your treating doctor or your IME doctor may order the test, which is usually performed by a physical or occupational therapist. During the FCE, you will be asked to perform a series of physical exercises that test your ability to do certain tasks, such as gripping, walking, bending, kneeling, and lifting. The doctor who ordered the report will then rely on the results to determine what type of work you can perform in the future.
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