by Kara Dolan-West | Dec 01, 2020 | Medical Care Benefits
When an individual suffers an injury at work, you may think that all of the medical expenses associated with that injury should be covered until the individual is fully recovered. Unfortunately, this may not always be the case.
Ohio Revised Code Section 4123.54 holds that every employee who is injured or who suffers an occupational disease related to work, is entitled to receive medical services. Section 4123.66 authorizes the Administrator of the Bureau of Workers’ Compensation to pay for the medical services from the State Insurance Fund for such medical services and medicine that the Administrator “deems proper.” This can be a difficult burden to meet for some injured workers.
The first hurdle in obtaining medical coverage under the Ohio Workers’ Compensation system is allowance of your claim as a whole. Remember, you are only eligible to seek coverage of medical expenses and supplies under the claim if the claim is deemed related to your work activity and is considered “allowed.” If your claim is disallowed, you will have no chance of obtaining medical coverage under the claim for your injuries. If you receive a denial on your claim, you may want to consult with an experienced workers’ compensation attorney right away.
Once allowed, your claim must be allowed for the conditions upon which your physicians are requesting treatment. For example, if you suffer a work-related injury to your shoulder causing a shoulder sprain and tear of your rotator cuff, but the claim is only allowed for the sprain, you may have trouble obtaining approval for ongoing medical care without the claim also including the tear to your rotator cuff.
Specifically, to make sure your claim is allowed for the appropriate conditions, you may want to consult with legal counsel to ensure that you obtain the requisite medical documentation to support your requests. Often times, a physician may state that an injury occurred and diagnose the condition, but the physician may fail to causally relate the condition to the injury. This type of specific statement may be the difference between medical coverage of certain procedures being granted and denied. If you are concerned that you may not receive medical coverage of the medical care you need due to a work injury, you should contact an attorney right away for assistance at The Bainbridge Firm.
Finally, once your claim is allowed, and the claim includes the necessary conditions upon which you need treatment, the treatment request must comport with what we call “The Miller Criteria.” This means that your medical coverage request must meet three (3) criteria to be approved: (1) the requested services are reasonably related to the allowed conditions; (2) the requested services are reasonably necessary for treatment of the allowed conditions; and (3) the cost of the services are medically reasonable.
It is important – and sometimes critical to your claim – to obtain medical documentation that supports the treatment you are requesting as required under The Miller Test. Often times, a licensed attorney can be instrumental in working with your physician to make sure the medical reports state the necessary language to better your chances at medical coverage.
If you have been hurt on the job and need medical attention or medication, contact a workers’ compensation attorney near me at The Bainbridge Firm who knows just what to do to provide you with the best fighting chance at approval.
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