Being injured at work is stressful enough without worrying about whether your medical treatment will continue. You are dealing with pain, recovery, and the uncertainty of when you can return to work. The last thing you should have to worry about is losing access to the medical care you need.
Many injured workers in South Carolina do not realize that their right to medical coverage extends beyond their initial treatment. Even after you reach what doctors call “maximum medical improvement,” you may still be entitled to ongoing medical care through workers’ compensation. Understanding how to protect this coverage can make the difference between a full recovery and struggling with untreated pain for years. Our experienced Columbia workers’ compensation lawyers can help.
What South Carolina Law Says About Medical Coverage
Under Title 42 of the South Carolina Code of Laws, workers’ compensation covers all medical treatment that “tends to lessen the degree of disability” from your work injury. This is not limited to the immediate aftermath of your accident. The law requires your employer’s insurance carrier to pay for treatment that helps you heal and maintain your recovery.
In South Carolina, your employer has the right to choose your initial treating doctor. While this may feel limiting, it does not mean you have no say in your medical care. If you are not satisfied with the treatment you are receiving, you have the right to request a different physician within the authorized provider network.
Understanding Maximum Medical Improvement
Maximum medical improvement, or MMI, is a term that often confuses injured workers. MMI means your condition has stabilized to the point where additional treatment will not significantly improve your impairment. However, reaching MMI does not mean your medical coverage ends.
This is a critical distinction that insurance companies often try to blur. Even after MMI, South Carolina law requires coverage for medical treatment that would “lessen the period of disability.” This includes treatments that maintain your current level of function, such as ongoing physical therapy, pain management, prescription medications, or future surgeries.
Your treating physician will complete a Form 14-B stating whether you need additional medical care after reaching MMI. If the doctor recommends ongoing treatment, the insurance carrier must make a decision about whether to approve it. If they deny necessary treatment, you have the right to challenge that denial.
Document Everything Your Doctor Recommends
Keep copies of all medical records, including your doctor’s recommendations for future care. These documents become crucial evidence if you need to fight for continued coverage. Your doctor’s opinion about what treatment you need carries significant weight with the South Carolina Workers’ Compensation Commission.
Common Tactics Insurance Companies Use to Cut Off Medical Coverage
Insurance companies are in the business of minimizing costs. Having worked on the insurance company’s side and within the SC Workers’ Compensation Commission, the attorneys at Williams & Roche, LLC understand the tactics used to deny or delay medical coverage.
One common approach is to send you to an independent medical examination (IME) with a doctor chosen by the insurance carrier. These doctors often downplay your injuries or claim you no longer need treatment. Remember that you have the right to challenge an IME physician’s findings with evidence from your treating doctor.
Another tactic is to claim that recommended treatment is not “reasonable and necessary.” The insurance company may argue that your doctor’s treatment plan is excessive or experimental. This is where having detailed medical records becomes essential. Your treating physician should document why each aspect of your care is medically necessary.
Insurance adjusters may also pressure you to settle your claim quickly, before you fully understand what future medical care you will need. A settlement that closes out your medical benefits means the insurance company is no longer responsible for any future treatment related to your injury. Do not accept a settlement without understanding exactly what medical care you are giving up.
If the insurance company is denying necessary treatment or pressuring you to settle, call Williams & Roche, LLC at 803.784.0503. We can review your situation and protect your right to ongoing medical care.
Steps to Protect Your Ongoing Medical Coverage
First, report your injury to your employer immediately. South Carolina law requires you to report workplace injuries within 90 days, but waiting can hurt your claim. The sooner you report, the sooner you can begin receiving medical treatment.
Second, always see doctors authorized by your employer or their insurance carrier. If you receive treatment from unauthorized providers, the insurance company may refuse to pay. However, if you are dissatisfied with your authorized doctor, request a change rather than going outside the network.
Third, attend all medical appointments and follow your doctor’s treatment plan. Missing appointments or failing to follow through with prescribed treatment gives the insurance company grounds to argue that your condition has improved or that you are not serious about your recovery.
Fourth, keep detailed records of all medical treatment, including dates, providers, medications, and your symptoms. If the insurance company later disputes the necessity of ongoing care, your records will be essential evidence.
Finally, do not sign anything from the insurance company without having it reviewed by an attorney. Agreements to settle your claim often include language that closes out your right to future medical benefits. Once you sign, you cannot go back if your condition worsens.
What If You Are Worried About Employer Retaliation?
Many injured workers fear that fighting for medical coverage will result in job loss or other retaliation. South Carolina law prohibits employers from retaliating against employees for filing workers’ compensation claims or pursuing benefits. If you experience retaliation, you have legal options. Williams & Roche, LLC can help you protect both your medical benefits and your employment rights.
When To Get Legal Help
If your employer’s insurance carrier denies necessary medical treatment, delays approval for procedures your doctor recommends, or pressures you to settle before you understand your future medical needs, contact Williams & Roche, LLC. With over 50 years of combined legal experience and backgrounds on all sides of the workers’ compensation system, our attorneys understand how to fight for the medical coverage you need.
You generally have two years from the date of your injury to file a workers’ compensation claim in South Carolina by submitting Form 50 to the Workers’ Compensation Commission. However, do not wait until the deadline approaches. The sooner you have legal representation, the better protected your rights will be.
Frequently Asked Questions About Ongoing Medical Coverage
Can the insurance company stop paying for my medical treatment after I reach MMI?
No, not if you still need treatment. South Carolina law requires coverage for treatment that lessens your disability or maintains your level of function after MMI. If your doctor says you need ongoing care, the insurance company must pay for it.
What if the insurance company’s doctor says I do not need more treatment, but my treating doctor disagrees?
Your treating physician’s opinion carries significant weight. You can challenge the insurance company’s denial with evidence from your doctor. An attorney can help you present this evidence effectively to the Workers’ Compensation Commission.
Can I change doctors if I am not happy with my current treatment?
Yes, but you must request a change within the authorized provider network. Going to an unauthorized doctor on your own may result in the insurance company refusing to pay for that treatment.
What happens if I settle my workers’ compensation claim?
It depends on the type of settlement. Some settlements leave your medical benefits open, allowing you to receive future treatment. Others close out all benefits, including medical coverage. Do not sign any settlement without understanding what medical care you are giving up.
How long does workers’ compensation medical coverage last in South Carolina?
Medical coverage continues for as long as you need treatment related to your work injury, even after you reach MMI. There is no set time limit if the treatment is medically necessary to lessen your disability.
Get Help Protecting Your Medical Benefits
Do not let an insurance company cut off the medical coverage you need to recover from your workplace injury. Williams & Roche, LLC, represents injured workers throughout South Carolina. Our attorneys know the system from all sides and understand how to protect your right to ongoing medical care.
Call 803.784.0503 today for a consultation. We will review your situation and explain your options for protecting your medical benefits.
