Worker’s compensation in California generally covers reasonable and necessary medical expenses related to a work-related injury or illness. This includes various types of medical treatment, such as doctor visits, hospital care, surgeries, medications, physical therapy, diagnostic tests, and rehabilitation services.
However, there are a few factors to consider regarding the coverage of medical expenses:
- Authorized treating physician: In most cases, the medical treatment must be provided by a physician within the employer’s Medical Provider Network (MPN) if one is in place. If there is no MPN, you may have the flexibility to choose your own doctor for treatment. Seeking treatment from an unauthorized provider may result in the denial of coverage for those expenses.
- Reasonable and necessary treatment: Worker’s compensation covers medical treatment that is reasonable and necessary to treat the work-related injury or illness. The treatment should be directly related to the injury and aimed at alleviating or improving the condition caused by the work-related incident. Experimental or alternative treatments not considered standard practice may not be covered.
- Utilization review and medical necessity disputes: The insurance company or employer may request utilization review to determine the medical necessity of certain treatments. If there is a dispute regarding the medical necessity of a particular treatment, it may be subject to review and potential challenges.
- Pre-authorization requirements: In some cases, certain treatments or procedures may require pre-authorization from the worker’s compensation insurance carrier before they are performed. Failure to obtain pre-authorization may result in denial of coverage.
It’s important to communicate with your authorized treating physician and follow the proper procedures to ensure that your medical expenses are covered. If you encounter any issues or disputes with the insurance company regarding coverage, it can be beneficial to consult with a worker’s compensation attorney who can advocate for your rights and help navigate the process.