Reporting Work-related Injuries. Why This Is So Important:
The New Jersey Workers’ Compensation system provides benefits to those who suffer work-related injuries. There are three (3) main benefits; 1) the Workers’ Compensation insurance company must pay 100% of your medical bills; 2) the Workers’ Compensation insurance company must pay your lost wages while you are temporarily unable to work; and 3) if you are left with a permanent injury, you are entitled to receive a monetary award for the permanent disability you suffer. These benefits are not automatic. For example, you cannot choose your own doctors. You have to go to the Workers’ Compensation doctors and you can only receive your temporary lost wages if it is the Workers’ Compensation doctor keeping you out of work.
What happens if you do not timely report a work-related injury and use your health insurance instead?
Your health insurance company might not catch on at first. However, once medical bills for treating the work-related condition begin to pile up or your doctor scheduled you for surgery, your health insurance company will look for any reason they can find to deny your claim. Once your treatment is denied by your health insurance company, it may be too late to file a Workers’ Compensation claim.
Generally, the time for reporting a work-related injury is ninety (90) days. However, in certain instances such as being diagnosed with a work-related hernia, you must report the injury to your employer or their Workers’ Compensation carrier within forty-eight (48) hours of the diagnosis.
Here is what will happen if you do not promptly report a work-related injury. You may feel that you have adequate health insurance and that you do not want to make a claim against your employer’s Workers’ Compensation carrier. However, if the condition turns out to be serious and you need surgery, your health insurance carrier will look for reasons to avoid paying for an expensive procedure. The first thing they will look to is your occupation and try to determine if the injury is work-related. Your health insurance can easily deny you medical treatment because the treatment you are seeking is for a work-related injury. If too much time has elapsed from the onset of the injury, Workers’ Compensation will not pay the bills either, leaving you essentially uninsured and getting stuck with your own medical bills. This is particularly dangerous in instances where you receive the treatment and believe your health insurance is going to pay for the same. After you received the expensive treatment, you receive a denial from your health insurance carrier, leaving you stuck with the bill.
If you think this can’t happen, think again. I have seen it happen over and over again in my practice.
One of the most heart wrenching cases involved a client who had worked as a butcher for over twenty (20) years. As a butcher, he worked in cold spaces, lifted heavy things such as sides of beef, and repeatedly used a saw to saw through animal bone. Eventually, he developed pain in his neck and shoulder but did not report it as a work-related injury. An orthopedic surgeon determined that he needed surgery on his neck and shoulder and his health insurance company preapproved this surgery. However, after the surgery, the health insurance company determined that his injuries were caused by years of working as a butcher and should have been covered under Workers’ Compensation insurance. The health insurance company refused to pay the bill and I sued them in federal Court. I simultaneously submitted a claim to his Workers’ Compensation carrier. The Workers’ Compensation carrier denied the claim as well because my client did not have prior authorization from the Workers’ Compensation insurance carrier for the treatment. Also, we lost the case against the health insurance carrier because the Court upheld their exclusion on benefits for work-related injuries. I was able to procure a modest settlement from the Workers’ Compensation carrier for my client’s permanent injury which paid part of the medical bills which totaled over $100,000.00. The settlement I was able to obtain saved my client from bankruptcy but it was not an easy case.
Don’t let this happen to you. If you have any questions about work-related injuries, please call me for a free no obligation consultation.
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