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Medical Benefits

1. What are medical benefits and how do I get them?

Medical benefits are 100% payment by the insurance company for any treatment for a compensable injury through an appropriate healthcare provider. This can include physical therapy, surgery, medications, diagnostic testing, psychological counseling, injections, hospitalization, and other medical care.

Medical care, except in emergency situations, is generally paid by the insurance company when it is given by or at the referral of your primary treating doctor recognized under the claim and either preapproved as medically necessary or reviewed later for payment after the service is performed.

Generally, you cannot seek medical care on your own, outside the workers' compensation system, and get reimbursement for your costs. Exceptions may apply.

2. I'm hurt and in pain. How can I find a doctor who will treat me for my injuries?

In Texas, you have the right to choose your own workers' compensation doctor. In a case where your employer is not part of a "workers' compensation healthcare network," you may choose almost any doctor willing to treat you under Texas workers' compensation law. In cases where your employer does have coverage through a workers' compensation heathcare network, your right to choose a doctor is limited to doctors within the network, and even there, you can only make your own choice of doctor once without special circumstances. To find out, ask your lawyer or, if you do not have an attorney, inquire with the insurance carrier or employer.

Many of the doctors in healthcare networks work for medical clinic chains such as Concentra or Texas Medclinic. Often you will find that those doctors, though very personable themselves, must avoid conflict with the insurance companies and employers that keep them supplied with patients. Very often they will avoid confronting an insurance adjuster about a denied claim even when the medical proof is quite strong because they cannot risk getting involved.

When seeking medical care through a network, it is important to have the counsel of an experienced attorney who knows how to select a doctor that will work for your best interest. There are also exceptions to the network requirements that may allow you to select your own doctor even when your employer has chosen to be covered through a network.

If your claim is not part of a network, you can look for a treating doctor (primary doctor) or specialist HERE. Keep in mind that an experienced lawyer will know the reputation of many doctors in the area who practice occupational medicine.

If your claim is part of a network, you or your attorney may obtain a list of network doctors through the insurance company.

For Texas Mutual Insurance, a list of network providers can be found HERE.

For Travelers Insurance and its related companies, a list of network providers can be found HERE.

For Liberty Mutual Insurance and its related companies, a list of network providers can be found HERE.

3. I've been told my "case is closed" and I can't see a doctor anymore. Can they do that?

By law, every workers' compensation claim comes with lifetime medical care for the compensable injury. That is, any medical condition or diagnosis that is either accepted by the insurance carrier or ordered as compensable by a hearing officer or judge comes with lifetime medical care.

However, lifetime medical care does not mean a "blank check" for your doctor to do whatever he wishes.

All healthcare providers must prove that the treatment they are requesting is both for a covered diagnosis and meets standards of evidence-based medicine for medical necessity. In plain language, that means they have to show the treatment is both for a medical condition that is related to the injury and that the medical treatment is shown in the relevant medical literature to benefit patients in your situation through a proven track record of success. If your injury has resolved or there is no longer any treatment available that will benefit you, then your right to lifetime medical treatment is effectively over. But the insurance carrier cannot prevent you or your doctor from trying to prove that your injury has not resolved and you still need help.

Often, the insurance company will try to make it seem that no treatment is necessary even when you are still in pain and your doctor is hard at work trying to help you. They may request a doctor to either give you a physical examination or review your medical records. In either case, the doctor will issue a report that will guide the insurance adjuster in evaluating your medical bills and the doctor's requests for treatment.

When the doctor physically examines you, this is called a "required medical examination." The insurance company has certain rights to require you to submit to an examination by a doctor of their choice. Your attorney can determine if you must submit to the request or if the insurance company is attempting to go beyond what the law allows in forcing you to submit to unnecessary evaluations.

When the doctor merely reads your past medical records and offers a report, this is called a "peer review." The insurance carrier has the right to send your records for a doctor to review, but it is important to determine if all the relevant records were sent, if the information provided to the doctor was otherwise accurate, and how this doctor's report is being used against you.

Regardless, you do not have to let the insurance doctor have the last word in your case. Your doctor and attorney can work together to request a hearing if that doctor's opinion is blocking important medical care.

Contact San Antonio Workers Compensation and Accident Lawyer Alan Tysinger

Suffering an on the job injury or losing a loved one to an accident is an emotional and difficult challenge. Battling with insurance and getting the right legal answers is something you won't want to do alone. Attorney Alan Tysinger has experience and know-how to get to the truth of your injury case and hold the insurance or employer accountable. You can get a free consultation with a personal injury lawyer in San Antonio by calling toll-free 866-957-2667 or send a message online.