Sections 13 & 30 Medical Benefits

M.G.L. Chapter 152, Sections 13 & 30 are the sections of the Massachusetts Workers Compensation law that provides for the payment of work related medical benefits to the injured employee.

Section 30 provides: “The insurer shall furnish to an injured employee adequate and reasonable health care services, and medicines if needed, together with the expenses necessarily incidental to such services…”

What this means, generally, is that the workers compensation insurance companies will provide medical benefits so long as the proposed treatment is reasonable, necessary, and causally related to the work related injury. While this sounds simple in theory, in practice, the process is often rather cumbersome and complex. That is not to day the the various insurance companies are always difficult to deal with. On the contrary, very often the insurers will approve and authorize the proposed treatments rather quickly. Together with paying weekly disability benefits, under Sections 34, 35, and 34A, many times a workers’ compensation case will not require the employee’s attorney to get involved right away. In situations like these, however, it is still advisable to retain an north shore workers comp lawyer to “keep and eye” on the situation and ensure that workers comp acts properly.

However, equally often are situations where getting the appropriate treatment is very difficult. This is mainly because there is a specific process when requesting medical benefits and this process takes time. Time is immaterial to an insurer but is very important to the injured employee. The last thing the injured worker wants to hear is that it may take a month or more for the insurer to approve a requested medical procedure.

Why Not Just File a Claim?

It would be much easier if the law allowed an employee’s workers compensation attorney to file a claim right away to get the insurer to act. However, unless various steps are exhausted first, a claim will not be allowed to proceed to a Judge for an order of payment. This process, known as the Utilization Review (“UR”) process, is required for any doctor requesting treatments through workers’ compensation insurance.

The process if summarized as follows. The doctor’s office must submit the proposed treatment through UR. This is done usually by faxing a request. UR then conducts a review to determine if the proposed treatment is reasonable and necessary. That is their only charge: reasonableness and necessity.

If approved, it moves onto the adjuster. If it gets denied, the doctor’s office MUST appeal the decision. Then, only upon a second denial can a claim get through the workers comp court system.

If the UR provider approves the treatment, it then moves to the workers compensation insurance adjuster for the final stamp of approval. The adjuster can simply deny the treatment outright, at which point a claim can be filed.

What if the Adjuster Approves the Treatment?

If the adjuster gives his/her stamp of approval, the last step is to agree on a fee for the proposed treatment. Section 13 indicates that the workers’ compensation insurance company only has to pay what is known as a DIA Board Rate for any said treatment or procedure. Very often, they will negotiate with doctors on this rate, however, often they insurer and doctor are unable to agree on a fee. At this point, the process can come to a quick halt, and employee’s attorney must then advise their clients that they have to seek another doctor who will do the procedure for less.

As you can see, this process is both lengthy and cumbersome. To an injured worker, it can be incredibly frustrating and downright annoying. That is why retaining an experienced workers comp lawyer as early as possible, to advise the injured worker during this difficult time.

If you have sustained a work related injury and need medical care, contact an experienced workers comp lawyer as soon as possible.

At Troupe Law Office, we have been representing injured worker for close to 50 years, and have consistently achieved favorable results for our clients.

Call us any time to discuss your workers compensation case.