Q: If an injured worker is denied recommended medical care, but has group medical coverage through the employer can they turn it in under their group coverage? Can both workers' compensation insurance and group deny my claim? Will the employee be dunned by collection notices if this happens?
A: Yes, the injured worker can turn their medical expenses in under group, or individual nonoccupational insurance, so long as they meet the other requirements of the coverage, and if, payment is refused because of a workers' compensation claim, the nonoccupational carrier's attention should be directed to §85.38(2), Code of Iowa, second paragraph. This is true whether of not a contested case is on file, and appears to be true even if the primary insured is a spouse of the injured worker, so long as the injured worker is covered too. This, of course, does not mean that the nonoccupational carrier will necessarily pay without a fight. However, if a contested case is pending before the Workers Compensation Commissioner which has not yet been decided, the worker is entitled to the protection of §85.27(6), which provides that no debt collection, as defined under §537.7102, may be undertaken while the case is pending before the Workers Compensation Commissioner. The provider may only send one itemized bill after they are notified of the pending contested case.
An injured worker who tells care providers that their condition is not work related just to obtain coverage under a nonoccupational plan may severely undermine their claim for workers' compensation benefits by destroying their own credibility. If a worker thinks their condition may be work related, they should be consistent in saying so at every opportunity.
The possibility of having to repay the medical insurance carrier, should be discussed with counsel.
If you have questions, or find yourself caught between the workers compensation and group carrier, with no one paying for your medical care, and the providers dunning you, you should promptly consult counsel.
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