Does Workers’ Comp pay for a doctor’s visit?

Ever wondered if workers’ comp insurance pays for a doctor’s visit? Well here’s the short answer: YES. Let’s take a look at some of the details.

First off, what does work comp insurance actually cover?

If an employee suffers a work-related injury or sickness, work comp benefits are mandated to cover the following:

• Medical expenses related to your work injury;
• Lost wages due to time off work;
• Ongoing care costs;
• In worse cases, funeral expenses.

If an employee gets sick or injured at work, workers’ comp benefits pay for medical expenses related to the resulting injury. Those expenses include doctors’ visits, medical tests (e.g. x-rays, blood tests), rehabilitation, emergency room care, hospital stays, and in some cases, even transportation costs.

These same benefits are revoked once it is proven that a worker's injury or illness were obtained outside of work. The same goes for any accidents occurring as a result of intoxication, or worse, if employees were found to have intentionally caused the injury themselves.

In a normal setting, however, it’s important to keep in mind that regulations and guidelines for approval of medical expenses in relation to a work comp claim varies from state to state. But in a general sense, all states’ work comp programs pay for every injured workers’ doctor visits but it’s not without its limitations.

Is there a limitation to the number of times a patient can visit the work comp doctor?

States have certain statutory limits for the different forms of treatment injured workers receive - doctors’ visits included. The point is, there is no fixed number of visits to which a patient can actually ‘use up’.

The main idea is that the workers’ compensation system will pay for an injured worker’s doctor visit as long as it is still necessary for their case. The same goes for treatments that require multiple sessions, such as physical therapy. In most states, additional sessions will also be paid by the work comp system if the doctor deems that further treatment would be beneficial to the injured worker.

Alternatively, the employer may also disagree and seek a second opinion to assess whether said additional treatment would really improve your condition. While the patient may not agree, it is well within their rights to do so and injured workers must comply otherwise your work comp benefits will likely be suspended.

What treatments are NOT covered by work comp benefits?

Any standard treatment will most likely be covered by an injured worker’s work comp benefits. But alternative treatments such as oriental medicine (e.g. acupuncture), naturopathy, Ayurveda, etc. or experimental treatments are usually not part of the coverage, although it can depend on state guidelines. Nevertheless, these types of treatments are allowed as long as the injured worker is able to pay for it out of his/her own pockets.

So who exactly pays for my doctors’ visits?

Ultimately, the onus of paying for an injured worker’s doctors’ visits (or any medical expenses, treatments, etc.) falls on the employer.

Regardless of the state, it is the employers who pay for workers’ compensation insurance. Employers may purchase this coverage through two types of recognized entities namely (1) state-run insurance programs and; (2) private insurance companies. It differs from health insurance in such a way that work comp insurance is not deducted from employee payroll.

If, for instance, an employee’s work comp claim is denied, he/she can pay for his/her own bills and seek reimbursement from the insurer once the denial is reversed on appeal. Alternatively, there are work comp doctors who might agree to treat patients on a lien basis. It means that any bills incurred will come out of recovery acquired through workers’ compensation.

On the other hand, there are states that offer a temporary disability insurance program where injured workers may be eligible to apply in order to cover up some out-of-pocket expenses.

When will the bills be paid?

Any open work comp claim should have the bills shouldered immediately by the insurance company whether it’s private or state-run. The same bills will continue to be paid as long as the patient continues to receive treatment and the claim is still open.

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