Why Your Prescription Drug Is Denied By The Worker's Compensation Insurer
There are only two situations in which a workers' compensation insurance company can legally refuse to pay for your medicine: the first is where a utilization review (UR) organization has made a final determination that the drug is not reasonable or necessary.
The "URO" process, however, is regulated and does not take place in secret. The injured worker knows when it starts, has a limited opportunity to participate, and gets a copy of the decision, which he or she can appeal. So there are no surprises at the pharmacy if the prescription is denied because of a final, unfavorable UR finding. The other legitimate reason for denial of the prescription is that the medication is "unrelated" to the injury for which liability has been accepted.
This is the area where all sorts of games can be played by the insurer. For example, in a case where the accepted injury is a low back strain (a very common description, even where the injury is actually more serious, such as a herniated disc), a physician may prescribe an anti-depressant, which has been found to be helpful in treating chronic pain. The insurance adjuster reviewing the claim will seize on the fact that the primary purpose of the drug is to treat depression (at least, that is why it was invented and approved) and, since the insurer never accepted legal responsibility for depression, will simply deny coverage for the drug. Even though it has a duty to investigate claims, it will not ask the doctor first why the drug was prescribed; it will deny first and answer questions later.
This puts another burden on the injured worker - now he has to prove that the drug really was intended to treat his low back injury. This means getting a letter or report from the doctor - not an easy thing to do; forwarding it to the adjuster, and hoping it will be acted upon. If it isn't (and during the delay, the symptoms go untreated), then the only recourse is a months long "penalty proceeding" where the worst punishment that can be inflicted for the wrongful denial is a 50% penalty of the amount that should have been paid for the medication. If the prescription would have cost $50, the insurer can be ordered to pay for it plus $25. Of course, it will have spent hundreds of dollars in its own legal expenses defending against the claim, if it persists in its denial.
Simply put, there is no financial incentive for the insurer to investigate the claim and pay it on time; there is no right to sue it, and the potential penalty is trivial. The cost to the injured party, in needless suffering and delayed treatment, cannot be measured in dollars.
About the Author
As a Workers Compensation Law firm in Lancaster PA who deals often with workplace incidents, we have learned to keep a flexible schedule in order to accommodate our clients' needs. Our Lancaster Workers Compensation Lawyers will keep the doors of our law office open to meet with you on your schedule, whenever your work and family allow. http://www.danslaw.com
Tell others about
this page:
Comments? Questions? Email Here