ARIZONA WORKERS' COMPENSATION SUMMARY
MEDICAL CARE UNDER WORKERS' COMPENSATION
Your right to medical care in a workers' compensation case is perhaps the single most valuable right you have. If you can prove that you need care as a result of the residuals of an industrial claim, that care continues for the rest of your life. The carrier/employer is responsible for paying 100% of your medical bills. A physician or health care provider, including pharmacists, cannot charge more than the amount provided for in the schedule of fees or charges provided by the ICA.
There are two basic kinds of medical care, "active" and "supportive." "Active" medical care is that care necessary while your case is open to improve your condition and includes any and all kinds of treatment "reasonably necessary" to return you to as close to your pre-injury status as possible. Once you reach maximum improvement, your condition is considered "stationary." "Supportive" medical care is that care necessary to maintain your condition after your condition becomes stationary and your case closes. (For more information, see the section on "Stages of Workers' Compensation.")
You have no "right" to "supportive care" unless your case closes with a permanent disability. Your medical care after closure is limited to what is in your Notice of Supportive Medical Maintenance Benefits. It is important that you use the care as set out in the Notice; otherwise the carrier/employer may attempt to terminate that care for lack of use.
Even after your case closes, if your condition worsens and/or your doctor finds something new that you can prove is causally related to your claim, you may "reopen" your case for "active" medical care. (For more information, see the section on "Reopening.")
Selecting Your Doctor
When a worker is injured on the job, IN MOST CASES THE WORKER CAN GO TO THE DOCTOR OF HIS/HER OWN CHOICE to treat the injury. However, there are some exceptions:
1. Self-Insurers: Some large companies are "self insurers." This means that they have complied with special laws and may provide their own doctors who will take care of workers' injuries. An example would be some of the large mining companies that also provide clinics for their workers. A worker is generally required to go to the doctor provided by a self-insuring employer for any treatment with the exception of employees of the State of Arizona or employees of any political subdivision of the state.
2. Treating Doctor: Once a doctor begins taking care of a worker's injury for a period of time, that doctor may become the "treating doctor." When a worker goes to a doctor at the recommendation of the boss or employer, the worker may be stuck with that doctor once the doctor becomes the "treating physician."
If in doubt about whether an employer can force a worker to go to his or her own doctor, call the Industrial Commission or consult a lawyer.
Treatment For Your Injury
Most of the time, the physicians who provide care for the injured worker take care of the ICA requirements for getting approval of treatment, but the worker still has a responsibility in regard to that care. If a worker needs a medical procedure, such as a surgery, he/she should have the approval of the carrier/employer before undertaking that treatment. At the very least the injured worker MUST GIVE THE CARRIER/EMPLOYER NOTICE of treatment or procedure, allowing ample time to permit them to get a "second opinion" if they so desire. The only exception is a true "emergency" where the worker or doctor does not have time to give notice. Most problems occur where the worker gets his or her treatment on their own or through private insurance and forgets to timely notify the employer/carrier. FAILURE TO GIVE PROPER NOTICE OF TREATMENT, EVEN IF THAT TREATMENT IS RELATED TO THE INJURY, COULD RESULT IN THE WORKER BEING HELD RESPONSIBLE FOR PAYMENT.
If during the course of treatment, a worker "unreasonably" refuses or interferes with medical care intended to improve his/her condition, that worker may have all benefits suspended. Such a suspension may only be granted upon application to the ICA and may not be undertaken by the carrier/employer without the ICA's approval. (This is different than the immediate suspension that can be imposed by the carrier/employer for failure to attend an "independent medical examination" as explained below.)
When a worker fails to continue to see his or her "treating" doctor, the carrier/employer may issue a letter advising that unless the worker immediately returns to the doctor, the carrier/employer will assume that there is no further need for treatment and close that worker's case. Such case closures are permitted without asking the ICA for permission and will become final unless a Request for Hearing is filed to protest that closure.
If a worker's medical care is restricted or terminated because of an examination by a doctor for the carrier/employer, the worker may still seek medical treatment at his or her own expense or through private insurance. (Timely "notice" of even this treatment must be given the carrier/employer as explained above.) Most of the time, the worker or the private insurance can be repaid for that treatment if the worker is successful in proving at a hearing that the carrier/employer doctor was wrong and that the additional treatment was "reasonably necessary" for the worker's recovery from the injury. (See "Hearings Before the ICA" for more information.)
Once a worker has established a "treating physician," the worker may not change doctors without following special steps outlined by the ICA. If a worker goes to a different doctor without the ICA's approval, the insurance carrier/employer can refuse to pay for the new doctor's bills. IN SHORT, YOU CANNOT CHANGE DOCTORS WITHOUT PERMISSION FROM THE ICA OR AT LEAST GETTING THE INSURANCE CARRIER TO AGREE TO THE CHANGE.
Independent Medical Examination (IME)
The insurance carrier/employer can ask a worker to go to a doctor they choose for an evaluation from time to time even if the worker has a treating doctor. This is called an Independent Medical Examination (IME). The carrier/employer is supposed to give the worker 10 working days notice of the IME. The worker must comply with the request unless excused by an Administrative Law Judge (ALJ) from the ICA. Failure to attend an IME can result in suspension of the workers' compensation benefits or the worker being charged for the missed visit or both. It may also result in the claim being dismissed.
If the worker believes that the IME will cause "annoyance, embarrassment, oppression or undue burden or expense," the worker may apply to an ALJ to be excused from attending the IME. This excuse is known as a "protective order." The request for a "protective order" must be filed with the ALJ within 2 working days after the worker or the attorney receives notice of the IME. Judges grant these "protective orders" only in the most exceptional circumstances so the worker should plan on attending the IME to avoid problems.
At the IME, the worker will probably be asked to describe how he or she was injured and the treatment that followed. It is a good idea to review any medical records and "history" of the injury or claim to refresh their memory about what occurred. It is also important that the worker treat the examining doctors with respect, but should keep in mind that what they say to those doctors will probably be revealed to the insurance carrier/employer. While being examined, the worker should be careful to describe their symptoms or complaints precisely since vague descriptions of pain or complaints make it difficult to make a diagnosis. They should be careful not to exaggerate or attempt to overemphasize their symptoms since the IME doctors look for and record any inconsistencies between their observations and the complaints of the worker. Simply put, be precise and tell the truth.
The worker has two important rights at the IME. First, the worker may, at his or her own expense, arrange to have a doctor of their choice attend the IME. Secondly, the worker is permitted to tape record the evaluation. If a recorder is used, the worker should let the doctors know they are recording the examination. The worker should speak up about any problems they have during the exam to make a record of what happened at the time of the exam. (The law is unclear as to whether a tape recorder can be used in a psychiatric or psychological IME.)