Medical Benefits And Workers' Compensation

Exposure for future medical care for the Employee/Claimant is a very important category of exposure for the Employer/Insurer in most Workers' Compensation cases. In many cases, future medical care presents the highest dollar exposure in the case; in other cases, it will rank second or third, after exposure for future TTD benefits and perhaps PPD benefits. In all cases, it is essential for the Employee/Claimant's attorney to have a solid grasp on the client's medical condition and prognosis, as well as the likely need for medical care going forward, including over the client's lifetime when such is at issue.

O.C.G.A. Sec. 34-9-200 through O.C.G.A. Sec. 34-9-208, along with the associated Board Rules, establish the general playing field regarding obtaining medical care for the injured worker in Georgia, and regarding payment for such care. O.C.G.A. Sec. 34-9-200 provides in pertinent part that:

(a) The employer shall furnish the employee entitled to benefits under this chapter such medical, surgical, and hospital care and other treatment, items, and services which are prescribed by a licensed physician, including medical and surgical supplies . . . . which in the judgment of the State Board of Workers' Compensation shall be reasonably required and appear likely to effect a cure, give relief, or restore the employee to suitable employment.

This subsection provides the essence of what is provided for the injured worker in a Workers' Compensation claim.

As discussed elsewhere herein, the Employer/Insurer is essentially given control of the injured worker's medical care in addition to being given responsibility for paying for such medical care. O.C.G.A. Sec. 34-9-201 and Board Rule 201 give the Employer/Insurer the ability to choose between three different methods for providing for medical care; the methods include a panel of physicians, a conformed panel of physicians, and a Workers' Compensation managed care organization (abbreviated WC/MCO). The statute and Board Rule contain the specific requirements for these arrangements.

Significantly, the Employer/Insurer also enjoys the benefit of significantly reduced costs for providing medical care for the injured worker. O.C.G.A. Sec. 34-9-205 provides in pertinent part that

"[f]ees of physicians, charges of hospitals, charges for prescription drugs, and charges for other items and services under this chapter shall be subject to the approval of the State Board of Workers' Compensation . . . . Annually, the board shall publish a list by geographical location of usual, customary, and reasonable charges for all medical services provided under subsection (a) of this Code section."

O.C.G.A. Sec. 34-9-205(a) and (b). Board Rule 203 provides in pertinent part that

"[m]edical expenses shall be limited to the usual, customary and reasonable charges as found by the Board pursuant to O.C.G.A. Sec. 34-9-205. Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable . . ."

Accordingly, taken together, O.C.G.A. Sections 34-9-203 and 205 and Board Rules 203 and 205 establish a playing field where the State Board of Workers' Compensation regulates the fees payable for medical services rendered to injured workers in Workers' Compensation claims. The Board does so by compiling a Fee Schedule which sharply limits the amounts that are chargeable for medical care and services rendered to injured workers. The Workers' Compensation Fee Schedule is presumed reasonable, and in the majority of cases will control the amount the Employer/Insurer must pay for the injured workers' medical care over the life of the claim, and over the life of the Employee/Claimant.

The upshot of this statutory scheme is that medical costs are considerably less in the Workers' Compensation system than may be encountered outside that system. Of course, this has a sharp impact on the exposure the Employer/Insurer faces for medical treatment of the injured worker, both during the claim and when evaluating future exposures for settlement purposes.

Insofar as medical care for the work-related injury is available to the Employee/Claimant for life, as long as such care otherwise satisfies the requirements of O.C.G.A. Sec. 34-9-200, et seq., future medical expenses are a very important area to consider in valuing a case for settlement. The more serious the injury, of course, the more serious will be the potential future medical costs. One area with large potential costs is pain management, which is a recurrent theme in Workers' Compensation practice.

There is no requirement that medical care be closed when a Workers' Compensation claim is settled. In prior years, it used to be the norm that cases would be settled with medical being left open for some period of months or years, with the Employer/Insurer continuing to pay for authorized medical during that time even though the rest of the case had been settled. Once the open medical period ended, the claim would be completed. Nowadays, however, it has become much more common for medical to be closed at the time the case is settled; many Employer/Insurers are reluctant to continue with open medical beyond the settlement.

If you are wondering if you are eligible for medical benefits under workers' compensation, then please do not hesitate to contact an Atlanta workers' compensation lawyer from our firm today! We have been practicing personal injury and workers' compensation law for over 22 years. Our legal team offers a free initial case evaluation so call our toll free number at (888) 665-7699. Our firm provides legal services in both English and in Spanish.

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