Medical BenefitsHow to receive medical benefits after a work-related injury.
Injured workers who have suffered a compensable workplace injury are entitled to receive medical treatment, at no cost, for as long as the authorized treating physician (ATP) relates it to the work-related injury. Medical benefits include medical care and payment of medical bills.
How to Receive Medical Benefits
If an injury requires immediate attention, emergency medical care may be required. Emergency care often occurs before any other medical care.
When not to go to the ER.
Emergency room visits might not be covered by your employer's workers' compensation insurance if the need for care is not immediate, necessary and reasonable.
Employers are responsible for medical care after they have knowledge of a work injury and the need for medical care. This begins with injured workers reporting the injury as soon as possible. Many employers ask for this to be in writing with detailed information including: the time, place, nature, and cause of the accident resulting in injury.
Tip: Keep a record of any evidence or information that might be helpful to help prove that your injury occurred while working and doing the employer's business.
Medical treatment begins with the injured worker selecting a medical provider from a list. The employer is required to provide a list of three.
The rule on providing a panel of physicians is:
“...an employer shall, as soon as practicable but no later than three (3) business days after receipt of such requests, provide the employee a panel of physicians as prescribed in TCA # 50-6-204. A medical provider must be qualified, willing, and able to treat in a timely manner the injury or condition reported to be listed on a panel.”
C-42 Employee's Choice of Physician (Spanish)
This form is the panel from which the injured worker chooses which doctor becomes the Authorized Treating Physician. A copy of this signed form must be given to the employee, and the original kept on-file with the employer.
Employees may also be asked to sign a Medical Waiver and Consent Form to allow the employer and/or insurance adjuster to receive copies of medical notes and reports.
Authorized Treating Physician
The physician selected by the injured worker is called the Authorized Treating Physician (ATP).
Injured workers and employers are encouraged to use care in selecting physicians. Researching the credentials of the panel physicians is encouraged.
Injured workers have a right to seek medical care by any other physician at the injured workers' expense.
Addresses the cause and extent of the injury
Injured workers must prove their injury was primarily caused by the work accident. An opinion from a physician relating the injury to the accident may accomplish this.
The opinions of an authorized treating physician selected from a panel of physicians is presumed accurate. An alternative opinion from another physician has to overcome this presumption.
Considers and creates medical records
Clear communications and discussions with physicians benefit the claim process. Injured workers are permitted to review medical records to make sure that everything shared with the physician makes it into a medical record.
Injured workers have a right to a copy of their medical records. There may be a nominal charge by the medical provider.
Establishes treatment plan
After reviewing records and necessary tests, the ATP will determine appropriate and necessary medical care. A nurse case manager may provide assistance.
Determines work restrictions and abilities
When it is appropriate for lifting, standing, or other similar restrictions to be made, the ATP will decide them.
Makes referrals to a specialist, if needed
Where specialized medical care is called for, the ATP makes the referral and the specialist becomes an ATP.
Calculates any impairment rating
If there is a permanent physical impairment to one or more body parts, the ATP will assign a permanent impairment rating based on the AMA Guides.
Medical care approval
Just because your ATP recommends a certain treatment, this doesn’t mean that the recommended treatment will be approved by your employer’s insurance company. Learn more about what to do if your care is denied in the section below, "Issues Receiving Care".
Nurse Case Manager
Insurance companies may assign a Nurse Case Manager to assist in coordinating care for workers with serious injuries. For example, they can help set appointments and assist in communicating with medical providers.
Medical benefits include medical/surgical treatment and supplies, medicine, crutches, nursing or psychological services, prescription eyeglass/eyewear, hospitalization, and dental work that is made reasonably necessary by the workplace injury.
The law requires employers to provide “reasonable and necessary” medical care to eligible injured workers. The employers must provide this lifelong treatment unless the parties reach a financial settlement to close medical benefits.
Closing Medical Benefits
Some workers choose to close their lifetime medical benefits. This is a voluntary decision that can be more complicated than many realize.
Workers are encouraged to carefully consider the impact that a decision to close medical benefits may have on Medicare or TennCare Benefits.
It is very important to inform your employer as soon as possible about your injury. The law provides that Notice to the employer is required to be given within 15 days of the injury. While there may be exceptions, a claim must be made within one (1) year of the date of injury.
If your employer's insurance company denies your claim, you have a couple of options:
● Seek your own care (out-of-pocket)
○ If your employer's insurance carrier denies the claim, you are free to seek medical care from wherever you choose. However, the payment for services and care would come out of your own pocket: not covered by your employer's insurance.
● Try your case in court
If your medical benefits are later found by the court to be the responsibility of the employer, the health insurance carrier may seek reimbursement.
Insurance Carrier Does Not Authorize Treatment
Since the injury is being paid for through your employer, they have a stake in what treatment you receive. If there is a disagreement that the recommended treatment is medically necessary (e.g. a full surgery for a cut), then our Utilization Review unit may become involved.
If you decide to pay out-of-pocket for another doctor’s impairment rating, the two reports can be reviewed through the Bureau’s MIR program.
Physician declines a patient
If any provider that the worker selected from a panel declines to provide treatment, the worker may either:
- Select another physician from the remaining physicians, or
- Request that the employer provides an additional choice of a physician to replace the physician who declined to accept the worker as a patient.
Every employer with five or more employees (and every employer in the construction industry) must have coverage. Very few exceptions exist in Tennessee law about being exempt or excluded from requiring workers’ compensation insurance coverage.
If your employer does not have workers’ compensation insurance, call an ombudsman for assistance at (800) 332-2667.