Defending Your Rights And Future And Seeking The Compensation You Deserve

What you need to know about workers comp coverage and denied medical bills

On Behalf of | Jul 5, 2024 | Workers' Compensation

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Workers in different industries face various risks due to their work environments. As someone who works in a physically demanding job, you face even more risks if you work in manufacturing, retail, construction and health care. 

Regardless of the industry, you should be able to get support from workers’ compensation if you suffer an injury on the job. However, as with any insurance-based program, there is a process where claims can be either approved or denied.  

Many injured workers’ main concern is what will happen to their medical bills when their workers’ comp claim gets denied. It is a common and valid worry. Getting hurt at work is stressful enough. A denied claim can make an already difficult situation even harder. Do not worry – you are not alone. You have options and resources to help with this situation.

This article will teach you what you need to know about South Dakota workers’ compensation and its coverage for medical bills. You will also learn why claims sometimes get denied and what you can do if you find yourself in this situation.  

Understanding workers’ compensation coverage for medical bills   

First things first, does workers’ comp cover medical bills? The short answer is yes, it should. In South Dakota, as in other states, workers’ comp insurance functions as protection for both employees and employers in case of work-related injuries or illnesses. It covers all reasonable and necessary medical expenses related to the injury.  

This includes doctor visits, hospital stays, treatments and even travel costs for medical appointments.

But what scenarios qualify an employee for workers’ comp coverage? Generally, if you are injured while performing your job duties, you should be covered. This coverage includes:   

  • Accidents on the worksite   
  • Injuries from repetitive motions (like carpal tunnel syndrome)   
  • Illnesses caused by exposure to harmful substances at work   

It is important to note that workers’ compensation coverage for medical bills can vary. In many states, including South Dakota, there is typically no set limit on the number of medical bills workers’ compensation covers. Instead, the coverage continues as long as your treatment is related to your work injury and deemed medically necessary.

Regardless of how many medical bills you accumulate, workers’ comp should cover them, provided they meet these criteria. This full coverage, along with other protections like disability rights in South Dakota, helps make sure you and other injured workers get support during recovery. 

What are the reasons a workers’ compensation claim could get denied?   

One of the most pressing concerns for injured workers is why workers’ comp is not covering their medical bills. Understandably, these expenses can quickly become overwhelming once they pile up. Various factors can lead to denials of workers’ compensation claims, leaving injured workers confused. Here are a few reasons this might happen:   

  • Missed deadlines: In South Dakota, you must report your injury to your employer within three business days. Failing to do so can result in a claim denial. Evidently, reporting on or before that third day is crucial for proper documentation and investigation of the incident.
  • Dispute over whether the injury is work-related: Your employer or their insurance company may argue that your injury did not occur during work hours or while performing job-related tasks. For example, they might challenge the work-relatedness of your injury if it happened during your lunch break or at a company social event.   
  • Lack of medical evidence: A claim denial may mean you need more medical proof to support your injury claim. It is crucial to go to the hospital as soon as possible after an injury and to follow through with all recommended treatments and appointments. Doing so creates a clear medical record that documents your injury, its severity and its connection to your work.  
  • Pre-existing conditions: If your pre-existing condition worsened due to a work incident, you might face challenges with your claim. The insurance company may argue that your current medical issues are solely due to your pre-existing condition rather than a work-related injury. However, as per state law, an aggravation of a pre-existing condition can still be compensable if the work incident was a major cause of the injury. Documenting the difference between your condition before and after the work incident is crucial.  
  • Suspicion of fraud: If your employer or their insurance company suspects that you are exaggerating your injuries or that the incident did not occur as reported, they may deny your claim pending further investigation. This is why it is important to be honest and consistent in all your statements about the injury.   

For instance, if you are thinking, “My employer did not pay my medical bill,” it could be because they are disputing your claim. Remember, determining who pays when you get hurt at work is not always straightforward – especially if there is a dispute. However, a denial does not mean the end of the road. There are several steps you can take after your workers’ comp application is unsuccessful.  

What options are there in case your workers’ comp claim gets denied?  

So, what can you do after a claim denial? Here are some steps to consider.   

Appeal the decision

You have the right to appeal a denied claim. This process typically involves filing a Petition for Hearing with the South Dakota Department of Labor and Regulation. You will need to gather all relevant documentation, including medical records and incident reports.   

The appeal process can be complex. It involves deadlines, paperwork and potential hearings. Understanding the specific reasons for your claim‘s denial is important to address them effectively in your appeal.   

File a lawsuit

Some injured workers consider suing their employer for denying workers’ comp. While this is possible in some cases, it should be a last resort after exhausting all other options. South Dakota law generally protects employers from workplace injury lawsuits if they provide workers’ comp insurance. However, exceptions exist, such as cases involving gross negligence or intentional harm. Before pursuing this option, it is crucial to understand the legal implications and potential outcomes.  

Negotiate with health care providers

Many medical providers understand the complexities of workers’ comp cases and may be willing to work with you. You can try negotiating a payment plan that fits your financial situation or ask about potential discounts for paying in cash.   

Some providers might agree to put your bills on hold pending the resolution of your case. Always be honest about your situation and keep detailed records of all communications with health care providers.

Check your health insurance

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When a workers’ comp insurer does not approve your claim, your personal health insurance may need to step in. However, it is crucial to understand that if you later win your workers’ comp case, you may need to reimburse your health insurance company. Contact your insurance provider to understand your coverage and any potential implications of using personal insurance for work injuries. 

Seek legal help

Workplace injury lawyers can guide you through the process and fight for your rights. They can provide valuable information about your rights, the appeals process, and potential strategies for addressing your situation. In cases where an employer did not pay medical bills, an attorney can help explore available options and potential remedies. Remember, knowledge is power when protecting your interests as an injured worker. 

Moving forward after a claim rejection 

Going through the workers’ compensation system alone can be challenging, especially when dealing with an injury. That is where an attorney experienced in workers’ comp denials comes in. They can protect your rights by evaluating your case, gathering evidence, handling the appeals process and dealing with insurance companies.   

Whether you are dealing with a complex case like workers’ compensation for a shoulder injury requiring surgery or other challenging situations, assistance is possible.   

Do not let a denied workers’ comp claim leave you wondering what will happen to your medical bills. It is important to remember that you have rights as an injured worker and there are resources available to help you overcome this challenge. 

The law provides protections for injured workers. Educate yourself about these rights, and do not hesitate to advocate for yourself. With the right information and support, you can work toward resolving your workers’ comp issues and focus on your recovery.