Who Pays Your Medical Bills When on Workers’ Comp in Pennsylvania?

One of the biggest problems for injured workers is that their injuries are expensive to treat.  The cost of visiting a doctor, let alone receiving surgery and other more extensive procedures, is more expensive than ever.  Getting these costs paid for is one of the major benefits of Workers’ Compensation.

Under Pennsylvania’s Workers’ Comp rules, your employer – most likely through their insurance carrier – is the one to pay for your medical bills.  This should cover any care related to the injury you suffered at work, but sometimes, connecting your injury and care needs to that work accident will be a challenge.  Unrelated medical care is paid for as normal, though your employer might stop paying your normal health insurance while you are out of work.

Call Cardamone Law at (267) 651-7945 for a free case review with our Certified Pennsylvania Workers’ Compensation Lawyers today.

Workers’ Comp Benefits for Medical Care in Pennsylvania

Section 306 of the Workers’ Comp Act lays out the coverage that an employer is required to cover after an employee’s work injuries.  This law broadly defines medical care and includes all-encompassing language like “medicines and supplies” to say that truly any and all necessary care related to your treatment should be covered.

Keep in mind, however, that the care must be necessary and related to your work injury to get it covered.  Your treating physician – usually chosen by your employer for the first 90 days of your care – will not want to recommend additional care beyond what is truly needed, and employers and insurance carriers will usually not allow you to suggest additional procedures or services you think you need without putting up a fight.

Additionally, the care has to be related to your injury.  If your work accident produced rare effects or uncommon health conditions that are not usually related to the injury you sustained, it may be difficult to link that injury – and the necessary care for it – back to the initial accident.

Covering Other Medical Care While on Workers’ Comp in Pennsylvania

If you or your family members need to go to the doctor for other reasons while you are on Workers’ Comp, that medical care will be paid out of pocket or covered by your employer-provided health insurance as usual.  However, your employer might be able to fire you or take you off their insurance while you are on Workers’ Comp; there is no requirement to keep you on benefits while you cannot work.  This means you might need to get COBRA, Medicaid, or an ACA healthcare plan through the Marketplace until you are able to return to work and get health coverage again.

Fighting to Get Care and the Costs of Medical Exams Covered

As mentioned, employers and their insurance carriers might try to deny coverage for certain care by arguing that it is not necessary to treat your condition or that some symptom is not tied to your work injury.  Our Philadelphia Workers’ Compensation lawyers can help you get the additional exams and medical records you need to show these expenses should be covered.

Examples

These problems are best highlighted through the example of CRPS – a health condition known as complex regional pain syndrome, where patients face extreme sensitivity and pain to touch and temperature in the affected area after an injury.  This condition can be difficult to link to the initial injury, given that it often has no physical symptoms.  If you are suffering from CRPS, it may take additional medical examinations and testing to gather the evidence to prove to your employer that the condition is real and that it is linked to your work accident.

When it comes to denied treatment, this issue might involve experimental, controversial, or novel treatments, which might be the only place to turn if more conventional treatments are not helping you.  For example, in Fegley v. Firestone (2023), a court required an employer to cover medical marijuana for an injured worker.

Injuries also often produce unexpected effects, though they might technically be foreseeable and should be covered.  For example, if you cut your hand and ended up suffering a bad infection that required amputation, that would be extremely rare.  However, your employer still has to cover it; they must cover the actual results of an injury, no matter how unlikely.  They may try to deny this, saying that the infection resulted from another incident after your initial work injury and or from a failure to follow your treatment plan.

Getting Exams/Medical Records

To fight denials like these, we might need additional examinations and medical evidence to get the court to agree that your care should be covered.  In the meantime, we might need to seek these exams from medical experts and doctors who need to be paid, but these added costs can often be claimed at the end of your Workers’ Comp case as costs of evidence under § 440 of the Workers’ Comp Act.

Although these exams are not truly “medical care,” the cost of these exams and tests should ultimately be reimbursed by your employer through your award in your case.  In the meantime, our lawyers may be the ones to cover the costs of evidence gathering.

Does the Employer or Insurance Carrier Pay for Medical Care in Pennsylvania?

The Workers’ Comp Act puts the burden of paying on your employer but requires them to get Workers’ Comp insurance.  What this means is that, at the end of the day, the medical care will be paid for by the insurance carrier instead of your employer.  It also often means that any of the challenges, petitions to terminate, denials, and other roadblocks will come from the insurance carrier, not your employer.

Your employer might not be involved in these decisions at all, and their contract with the insurance carrier will often leave the decision about whether to cover your care or not out of the employer’s hands.

If your employer does not have Workers’ Compensation insurance and cannot rely on their carrier to pay you, they are often responsible for the payments out of pocket.  However, there may be situations where your direct employer is a subcontractor for another company, and that company might be required to cover your injuries if your direct employer does not have the required insurance.

Call Our Pennsylvania Workers’ Compensation Lawyers Today

Call (267) 651-7945 for a free case evaluation with the Norristown, PA Workers’ Compensation attorneys from Cardamone Law.