Utilization Review

One of the most important legal rights of workers who are injured on the job in the state of New York is the right to medical care and other benefits through the workers’ compensation system. However, it is important to note that there are limitations on a worker’s paid medical treatment, including the possibility of a utilization review for determining the appropriateness of certain medical care. It is very important that a person who has been hurt at work understands their rights under the law as well as any restrictions on those rights. At the Law Firm of Valerie J. Crown, Attorney at Law, P.C., our Rockland County workers’ compensation lawyers regularly advise workers regarding their claims for benefits under New York law.

When a person suffers a non-work-related injury, he or she generally has the right to seek medical attention from the doctor of his or her choice within the bounds of any applicable medical insurance policy requirements. This is not the case with injuries that happen at work. Not every doctor accepts or has been approved by state authorities for the treatment of on-the-job accidents and illnesses, so it is important to verify that the doctor accepts workers’ compensation insurance.

In treating many common work-related injuries, such as carpal tunnel syndrome and injuries to the neck, back, shoulder, and knee, approved medical providers are required to follow the Medical Treatment Guidelines established by the New York Workers’ Compensation Board. In some circumstances, an approved doctor may submit a request for authorization for a particular course of treatment for an injured worker. This request is then submitted for utilization review, a process during which a separate medical provider looks over the patient’s medical records, state guidelines, and other documentation and then either approves or denies the treating physician’s request. If the request is denied, the injured worker may appeal that decision. It is advisable that an injured worker be represented by a skilled workers’ compensation lawyer during this often-complex process.

In addition to medical benefits, an injured worker may also be entitled to receive temporary or permanent disability benefits. The exact amount of these benefits depends upon several factors, including the worker’s rate of pay, whether or not the worker is given temporary work restrictions due to the injury, and whether the employee’s ability to earn a living in the future is negatively impacted by the injury.

The limitations placed on injured workers may seem unfair at times. It is important to note that workers’ compensation law is considered a “compromise” solution between workers, who need prompt and timely medical care and disability payments, and their employers/insurers, who want to control costs and filter out false claims as soon as possible. For this reason, workers’ compensation law differs substantially from the systems that are currently in place for either pursing a civil claim against someone whose negligence caused an injury or for pursuing rights under a health insurance or accidental injury insurance policy. In a negligence lawsuit, the defendant does not technically owe the injured person any money damages until a court of law enters a judgment in the injured person’s favor or when the parties have agreed to an amount of money damages. It is also important to discuss whether the injured worker has a claim for negligence against a culpable third-party (meaning someone other than the employer or co-worker). An injured worker may be able to pursue a negligence claim against the third-party even though there is a workers’ compensation claim against the employer.

The good thing about workers’ compensation is that, unlike in a negligence lawsuit, the employee does not have to prove that the employer was at fault in causing his or her injuries in order to be eligible for benefits. In New York, the employer is obligated to pay workers’ compensation benefits to a worker who is hurt at work, even if the worker, himself, caused the accident, as long as injury was not intentional or the result of intoxication or drug use. In exchange for the convenience of not having to prove fault and for having benefits start immediately after the injury, the worker typically receives less overall monetary payout than would have been available in a negligence case. Additionally, the employer or its insurance company has the right to exercise certain controls over the employee’s medical treatment, including the right to engage in utilization review, in an attempt to control costs and not spend money on expensive, but ultimately medically unnecessary, healthcare treatment.

Employers and employees do not always agree about the handling of a work injury claim. It is important for employees to know that they have the right to hire an attorney to assist them in pursuit of any and all workers’ compensation benefits, including the right to paid medical care. At the Law Firm of Valerie J. Crown, Attorney at Law, P.C., we advocate for those who have been hurt at work and need assistance pursuing their rights under New York workers’ compensation laws. For an appointment to learn more about our, please call us at 845-708-5900, call Valerie 24/7 on her cell phone at 845-598-8253, or contact us online. We represent injured workers throughout Rockland County and Greater New York, including in Orange, Ulster, Westchester, and Dutchess Counties.