Workers' Compensation

What Happens to Medical Bills When Workers’ Comp Is Denied?

25 Jul, 2022

Pen and stethoscope on top of the unpaid medical bill

Who Pays Medical Bills When Workers’ Comp Is Denied?

Quick Answer

If workers’ comp denies your claim, the insurance company may refuse to pay your medical bills unless the denial is overturned. In Illinois, you may be able to challenge the denial through the Illinois Workers’ Compensation Commission, request a hearing, use group health insurance while the dispute is pending, or seek payment through Medicare or Medicaid in certain situations.

A denied workers’ compensation claim can leave an injured worker facing unpaid medical bills, collection notices, delayed treatment, or pressure to use personal health insurance. This situation can be especially stressful if you needed emergency care, surgery, diagnostic testing, physical therapy, injections, or a long recovery period after a work-related injury.

The good news is that a denial does not always end the case. Depending on the facts, you may be able to file an application with the Illinois Workers’ Compensation Commission, request a hearing, appeal an unfavorable decision, or use other insurance options while the workers’ compensation dispute is pending.

What to Do if Workers’ Comp Refuses to Pay for Your Medical Bills

Option	What It Means	Why It Matters
File an Application for Adjustment of Claim	This formally opens your case with the Illinois Workers’ Compensation Commission.	It helps move the dispute into the workers’ compensation system instead of leaving the denial unchallenged.
Request a hearing	You may ask for a hearing before an arbitrator if the insurer refuses to pay benefits.	A hearing can address whether the injury is work-related and whether medical bills should be covered.
Use group health insurance	Your health insurance may pay some disputed bills while the workers’ comp case is pending.	The health insurer may later seek reimbursement from a workers’ compensation settlement or award.
Medicaid or Medicare	These programs may help pay medical bills in some situations if other coverage is unavailable.	They may have reimbursement rights if workers’ comp later pays the claim.
Appeal the denial	If an arbitrator upholds the denial, you may have appeal options.	Deadlines can be short, so acting quickly is important.
Speak with a workers’ comp attorney	An attorney can review the denial, medical records, work injury evidence, and unpaid bills.	Legal help may be important when the insurer disputes causation, treatment, notice, or the extent of the injury.

File an Application for Adjustment of Claim

If workers’ comp refuses to cover your medical bills, you may need to file an application for adjustment of claim with the Illinois Workers’ Compensation Commission. This application formally opens your workers’ compensation case with the commission. A Chicago workers’ compensation attorney can help prepare the claim, organize medical evidence, and respond to the insurance company’s denial.

You have three years after your work-related injury to file this application. If you fail to file within the specified time, the denial decision will be final, and it will bar you from receiving workers’ compensation benefits permanently.

Request a Hearing

Once you file your application for adjustment of the claim, the commission will assign a case number and an arbitrator to your case. This will enable you to move your claim forward by requesting a hearing. The hearing will be an opportunity to discuss your case with the assigned arbitrator and your employer.

Since you are dealing with unpaid medical bills, it may be advisable to request an emergency hearing and seek a faster decision. You can do this by submitting a Petition for Immediate Hearing. If your medical bills involve a serious workplace injury, a workplace injury attorney can help present the medical evidence and explain why the treatment should be covered.

The lawyer will ensure you have a strong claim and are ready for the hearing. The lawyer will help you understand the reasons workers’ compensation claims are denied and common pitfalls to avoid. The lawyer will also help level the playing field, especially if a team of lawyers is representing your employer.

How Medical Bill Disputes Work in Illinois Workers’ Compensation Claims

Quick Answer: In Illinois, disputed medical bills are usually handled through the Illinois Workers’ Compensation Commission. If the insurer denies the claim or refuses to authorize treatment, the injured worker may need to file an Application for Adjustment of Claim, request a hearing, and present medical evidence showing that the treatment is reasonable, necessary, and related to the work injury.

In Illinois, workers’ compensation generally covers reasonable and necessary medical treatment related to a work injury. Problems arise when the insurance company argues that the injury did not happen at work, the treatment is not necessary, the condition is pre-existing, or the medical bills are unrelated to the workplace accident.

When medical bills are denied, the dispute may involve several issues, including:

Causation: Whether the injury or condition was caused or aggravated by work.
Reasonable and necessary treatment: Whether the treatment was appropriate for the work injury.
Medical authorization: Whether the insurer should approve surgery, therapy, imaging, injections, or specialist care.
Independent medical examination: Whether the insurer is relying on an IME doctor to dispute the treating doctor’s opinion.
Temporary total disability: Whether the worker should receive wage benefits while unable to work.
Medical billing disputes: Whether providers, health insurers, Medicare, or Medicaid may seek reimbursement if workers’ comp later pays the claim.

Because these disputes can affect both medical treatment and unpaid bills, it is important to keep copies of denial letters, medical records, bills, explanations of benefits, work restrictions, and any communication from the insurance company.

File an Appeal

If the arbitrator decides to uphold the decision to deny your workers’ comp, you can file a Petition for Review to appeal that decision. You have 30 days from the date of the arbitrator’s decision to file this petition.

Three commissioners from WCC will receive the appeal, examine the arbitrator’s decision, and schedule a hearing date. You can submit written arguments to support your claim to the commission before the actual appeal hearing. You will have five to ten minutes to argue your case at the hearing. The commission’s decision will be ready within 60 days of the appeal hearing.

Why Would Workers’ Comp Deny Medical Bills?

Quick Answer: Workers’ comp may deny medical bills if the insurance company disputes whether the injury happened at work, claims the treatment is unrelated or unnecessary, argues that a pre-existing condition caused the problem, or relies on an independent medical examination to challenge the treating doctor’s recommendations.

Workers’ compensation insurers do not always deny an entire claim at once. Sometimes they accept part of the claim but refuse to pay certain medical bills, delay approval for treatment, or dispute future care. This can leave injured workers unsure whether they should keep treating, use health insurance, or wait for the workers’ compensation dispute to be resolved.

Common reasons medical bills may be denied include:

The insurer claims the injury did not happen at work.
The employer disputes that proper notice was given.
The insurance company says the condition was pre-existing.
The insurer argues that treatment is excessive or unnecessary.
The insurance company disputes a surgery recommendation.
An independent medical examination disagrees with the treating doctor.
The insurer claims the worker reached maximum medical improvement.
The medical provider submitted incomplete or disputed billing documentation.

If the denial is based on medical causation or treatment necessity, the worker’s medical records, doctor opinions, diagnostic tests, and work restrictions may become critical evidence.

Does Workers’ Comp Cover All Medical Bills?

Workers' comp generally pays medical bills that arise from reasonable and necessary treatment for a work injury. These bills may include emergency room care, hospital stays, doctor visits, diagnostic studies like X-rays and MRIs, rehabilitation treatment, medications, injections, and surgery. If the injury happened on a jobsite or during physical labor, related pages on construction accidents and lifting injuries may also be relevant.

The rules and procedures for approving medical bills associated with a workers’ compensation claim vary from state to state. In Illinois, for instance, workers’ comp will cover any necessary and reasonable medical treatment recommended by your doctor. Understanding these rules and other workers’ compensation laws can help you tell when employers violate workers’ compensation responsibilities.

Medical Expense	May Workers’ Comp Cover It?
Emergency room treatment	Yes, if the treatment is related to the work injury and considered reasonable and necessary.
Doctor visits	Workers’ comp may cover visits with treating doctors, specialists, and approved providers.
Diagnostic testing	X-rays, MRIs, CT scans, nerve studies, and other tests may be covered when medically necessary.
Physical therapy	Therapy may be covered when recommended for recovery from the work injury.
Surgery	Surgery may be covered if it is reasonable, necessary, and causally related to the workplace injury.
Prescription medication	Medication may be covered when prescribed for the work-related injury or condition.
Future medical care	Future treatment may be considered in settlement negotiations or disputed if the insurer denies ongoing responsibility.

What Options You Have if Workers’ Comp Denies Your Claim

If your workers’ comp has denied your claim, you might wonder, “what happens to medical bills when workers’ comp is denied?” The most important thing you should know is that you will have to cover the medical costs. Luckily, you do not have to pay them out of pocket. The following options might help you cover those medical bills:

Group Health Insurance

Many group health insurance providers will accept to cover accrued medical bills when your workers’ compensation case is unresolved. You can use your group health insurance policy or your spouse's policy to pay the disputed medical bills.

You may need to complete and submit a Notice of Dispute form to the relevant group health insurance company. You may also need to agree to repay the company from your workers’ comp settlement or award and sign a repayment agreement.

Chicago Workers’ Compensation Attorney Neal Strom

Your workers’ compensation lawyer can help address reimbursement issues with the group health insurance company and fight for the medical benefits, wage benefits, or settlement you may be owed. In serious injury cases, settlement value may depend on medical treatment, work restrictions, disability, and future care needs.

Medicaid

Medicaid might pay for your disputed medical bills if you do not have group health insurance. This state health insurance program is available to low-income earners with limited assets. You will be required to reimburse Medicaid for any medical bills that the workers’ comp should have covered.

Medicare

If you cannot access Medicaid, you may be eligible for Medicare. This federal health insurance is available to people with disabilities. You will qualify for Medicare after getting accepted for social security disability benefits. You will, however, need to wait for 29 months from your disability date to use Medicare.

What Should You Do If You Receive Medical Bills After a Workers’ Comp Denial?

Quick Answer: If you receive medical bills after a workers’ comp denial, save every bill and denial letter, notify the provider that the treatment relates to a workers’ compensation claim, avoid ignoring collection notices, ask whether health insurance can be billed temporarily, and speak with a workers’ compensation lawyer before agreeing to repayment terms.

Unpaid medical bills can create stress quickly, especially when hospitals, doctors, or collection agencies begin contacting you. Even if the workers’ compensation insurer denied the claim, you should keep careful records and avoid assuming the denial is final.

Steps to take include:

Save all bills and denial letters: Keep copies of medical bills, explanation of benefits forms, collection notices, and workers’ comp denial letters.
Tell providers the injury is work-related: Make sure hospitals and doctors know the bills are connected to a disputed workers’ compensation claim.
Do not ignore collections: Collection notices can create additional financial pressure, even while the workers’ comp case is pending.
Ask about health insurance billing: Group health insurance may be an option while the workers’ compensation dispute is unresolved.
Track missed work and restrictions: Keep copies of work notes, restrictions, and disability slips from your doctor.
Avoid signing repayment agreements without advice: Repayment or reimbursement agreements may affect what happens after a settlement or award.
Speak with an attorney quickly: Deadlines may apply, and medical evidence often becomes central to challenging the denial.

Pursuing Benefits for Medical Expenses

You must let your employer know that you have sustained a work injury to obtain workers’ compensation benefits. You should see a qualified doctor immediately after you suspect your injury or illness is work-related. The doctor will determine and document the extent of your injury.

Upon receiving your claim, your employer’s insurer will probably ask you about the injury or illness and require you to see a preauthorized medical provider for a comprehensive medical examination. The insurer will use the medical provider’s examination to figure out whether you are eligible for workers’ compensation payments and, if so, how much your claim will be worth.

You can increase your odds of getting maximum workers’ compensation benefits by knowing what not to say to the insurance adjuster. Your lawyer will guide you on engaging the insurance adjuster and mistakes to avoid while doing so.

If your workers’ compensation claim was denied and medical bills are piling up, contact Strom Yen Injury Attorneys to discuss your options for challenging the denial, protecting your medical treatment, and pursuing the benefits available under Illinois workers’ compensation law.

Medical Bills After Workers’ Comp Denial FAQs

Who pays medical bills if workers’ comp is denied?

If workers’ comp is denied, the insurer may refuse to pay the medical bills unless the denial is overturned. The injured worker may need to challenge the denial, use group health insurance temporarily, or explore Medicare or Medicaid options depending on the situation.

Can I appeal a workers’ comp denial in Illinois?

Yes. In Illinois, an injured worker may challenge a denial through the Illinois Workers’ Compensation Commission. This may involve filing an Application for Adjustment of Claim, requesting a hearing, presenting medical evidence, and appealing an unfavorable decision when appropriate.

Will health insurance pay medical bills while workers’ comp is disputed?

Group health insurance may pay disputed medical bills in some cases while the workers’ compensation claim is unresolved. However, the health insurer may seek reimbursement from a workers’ compensation settlement or award if workers’ comp later becomes responsible for the bills.

Can medical bills go to collections during a workers’ comp dispute?

Medical bills can sometimes go to collections if they remain unpaid while a workers’ compensation dispute is pending. Injured workers should keep copies of all bills and collection notices and speak with an attorney about how to handle unpaid bills connected to the claim.

Why would workers’ comp refuse to pay for treatment?

Workers’ comp may refuse to pay for treatment if the insurer disputes that the injury happened at work, argues the treatment is unrelated or unnecessary, claims the condition was pre-existing, or relies on an independent medical examination to challenge the treating doctor’s opinion.

Should I keep seeing a doctor if workers’ comp denied my claim?

You should not ignore medical care simply because workers’ comp denied the claim. Continued treatment may be important for your health and for documenting the injury. However, you should speak with a workers’ compensation lawyer about payment options and how the treatment may affect your claim.

About the Author

Kevin Yen is a partner with the law firm. Kevin has dedicated his professional career helping injury victims for over 25 years. He believes in sharing his knowledge and experience of the personal injury industry with the general public so that they can be smart consumers and not be exploited or mistreated. In addition to his blogs, articles and other writings, he also volunteers his time with a number of free legal aid clinics including churches and community outreach centers.