Whitt & Del Bueno, Attorneys at Law

Leaders in defending workers' compensation claims.

Articles

Having Their Cake and Eating It, Too

By Mike Del Bueno

In a compensable claim, workers’ compensation insurance pays for medical treatment the injured employee needs because of the work injury. Like regular health insurance, sometimes workers’ compensation insurance pays only a portion of the bill for medical treatment and the doctor or hospital writes off the unpaid amount.

The reason for the write off can be, for example, that the workers’ compensation insurance carrier has entered into a specific contract with the medical provider regarding things it will and will not pay for. The medical provider receives some benefit from this type of agreement too – for example, in exchange for writing off some types of provided treatment, the medical provider is used by the clients of the workers’ compensation insurance carrier for treating their injured employees.

But, what happens when the medical provider decides that it wants to get paid for all of the medical treatment it gave to an injured worker, despite the fact that it agreed with the workers’ compensation insurance carrier to not be paid for certain provided treatment? Our firm recently and successfully represented one of our clients with regard to this exact issue.

The medical provider tried to argue before the Commission a number of things, including arguments that the workers’ compensation insurance carrier was not a party to the subject contract. However, the Commission did not find that argument to have any merit, as the workers’ compensation insurance carrier paid for the medical treatment provided to the injured worker – clearly, it was a party to the contract! In short, the Commission concluded that the workers’ compensation insurance carrier had paid the proper amount to the medical provider based upon the subject contract and that the medical provider could not recover from the workers’ compensation insurance carrier the amount that it did not pay under the terms of the agreement.

There are a number of other cases like this one that our firm is currently representing the workers’ compensation insurance carrier in regard to. If you have a similar situation or problem that you are dealing with, give us a call and we will try to assist you, as well.