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Medical Benefits

In Vermont employers (or their insurance carriers) must pay for all reasonable, necessary, and related medical treatment and medications at rates set by the Vermont Department of Labor. This is a simple principle, yet it leads to many disputes within the Workers’ Compensation system.

Why You May Need a Lawyer to Secure Your Medical Benefits

Medical benefits are the single most expensive component of Workers’ Compensation for employers and insurance carriers. They amount to almost half of all Workers’ Compensation benefits paid out in Vermont. Because of this, employers and carriers have a huge incentive to try to control the type of treatment workers receive. Several ways in which they may try to do this include:

  • Sending a worker to the carrier/employer’s choice of doctors
  • Using a nurse case manager
  • Sending a worker to an “independent” medical examiner
  • Denying the preauthorization of treatment
  • Denying payment for treatment or medication
  • Writing letters to doctors

Sometimes carriers/employers use these options improperly. Jarvis & Modun will protect you from improper attempts to control treatment. If a genuine dispute arises about whether recommended treatment is reasonable, necessary, and related to work, Jarvis & Modun will fight to secure the treatment best for you.

Choice of Doctors

Choosing a medical doctor is one of the most personal choices anyone can make. A good doctor-patient relationship is based on mutual trust. Doctors make decisions that affect one of the most basic components of happiness: your health. This is not a responsibility that should be given to just anyone.

In Vermont, the employer may initially send you to a doctor of its choice. Sometimes the employer expects that this will then become the doctor who treats you throughout the course of your recovery. However, this doctor may not be the doctor who is right for you. If an employer has sent you to its choice of doctors, you have the right to switch to your doctor at any time. However, you must send written notice to the employer/carrier and the Vermont Department of Labor before you do so. Otherwise, the employer/carrier may try to deny payment for the treatment. If you hire Jarvis & Modun to represent you in your Vermont Workers’ Compensation claim, we will see to it that switching to the doctor of your choice is done correctly.

Nurse Case Managers

Employers and insurance carriers sometimes use Nurse Case Managers (NCM) to help manage an injured worker’s medical care. Sometimes NCMs are very helpful. The good ones act as a resource to help you understand your treatment options. They may also help expedite your doctor’s treatment recommendations. The bad ones try to control your medical treatment. NCMs should not tell your doctors what medical care you should receive. They should not push to have your doctor release you back to work before you are medically ready. They should not act as claims adjusters in the field.

Jarvis & Modun also believes that NCMs should not be present in the examination room when the doctor examines you. During a medical examination, the doctor should give you his or her full attention. The presence of the NCM during an examination can be distracting. It can also intimidate patients and deter them from being candid with or asking questions of the doctor.

If you feel that a NCM has not acted in your best interest, call Jarvis & Modun to discuss your situation. We can help.

“Independent” Medical Examiners

There is nothing “independent” about an Independent Medical Examination (IME). These examiners are the hired guns of Workers’ Compensation and Personal Injury law. Sometimes these hired doctors provide reasonable opinions. Other times they write reports that seem to have little relationship to the truth and are perfectly tailored to the employer/carrier’s interest in denying benefits.

Your employer or its insurance carrier has the right to send you to an IME to address medical issues arising from your claim. However, there are limits to this right. They cannot use an IME to deny a claim they have already accepted without reservation. They should not use an IME to address medical questions addressed in a previous IME. Nevertheless, these abuses sometimes occur.

If you have been denied benefits because of something said by an Independent Medical Examiner, you should seek representation. The Department of Labor requires that claims involving disputes between medical opinions go to a formal hearing. A formal hearing is like a trial. Witnesses are sworn to tell the truth and are subject to cross examination. The employer/carrier must be represented by a lawyer at formal hearing. You should have representation as well. If not, you are at a severe disadvantage.

If you have been denied benefits because of an Independent Medical Examination, call Craig Jarvis or Amy Modun at (802) 540-1030 for a free consultation. Put our experience to work for you.

Preauthorization of Medical Treatment

If a medical provider wants to make sure it will get paid for the treatment it recommends, Vermont provides a process by which the provider can seek preauthorization from the employer/carrier. If the provider wants to seek preauthorization, it must send a written request along with medical evidence to support of the request. The employer/carrier then has 14 days to investigate the request. The employer/carrier may do one of three things. It may authorize the treatment, deny the treatment, or notify the provider that it will undertake a medical review or examination. If it chooses the last option, it has an additional 45 days to conduct the review or examination before either accepting or denying the request.

Sometimes the employer/carrier abuses this process. Sometimes it fails to respond within the time allotted. Sometimes it denies preauthorization without any basis. At a minimum, these abuses lead to unnecessary delays in treatment. Sometimes the injured worker simply gives up because he or she becomes frustrated with the system. If the worker gives up, then the employer/carrier saves money.

Don’t give up. If you are having trouble getting the medical treatment you need, call Jarvis & Modun. We fight to get needed treatment for our clients.

Denials of Payment from Treatment or Medication

Whenever an employer/carrier denies the payment of a bill for treatment or medication, it must provide a reasonable basis for doing so. It cannot deny payment just because it doesn’t agree with the treatment or use of the medication. In most cases it must have a medical opinion saying the treatment or medication is not reasonable and necessary or is not related to work. Neither your employer nor its insurance carrier is a doctor. Their belief that a treatment or medication is unreasonable or unrelated to work does not count as a medical opinion. Nevertheless they sometimes try to deny payment of medical bills without a proper medical basis.

If your employer/carrier has denied the payment of a medical bill, give Jarvis & Modun a call. We want to see that your doctors get paid so they continue to give you the treatment you need.

Letters to Doctors

Sometimes an employer/carrier tries to control medical treatment by writing to your treating doctor. Whenever a worker makes a Workers’ Compensation claim in Vermont, the employer/carrier is entitled to receive a medical authorization from the worker allowing it to request medical records related to the work injury. In some cases it is permitted to write to doctors to seek medical information necessary for adjusting the claim. Whenever this happens, it should send a copy of the letter to the worker and his or her attorney.

Sometimes the employer/carrier abuses a medical authorization. Sometimes it requests records that go beyond the scope of the authorization and have nothing to do with the work injury. Sometimes it writes inappropriate letters to doctors, seeking to control treatment or to end it before it should end.

If your employer or its insurance carrier writes letters to your doctors, call Jarvis & Modun. Your employer/carrier may be trying to deny you the benefits you deserve.