Workers Comp & Health Insurance

[Layla]

Jurisdiction

Texas

What if you go through your Health insurance for a second opinion on the extent of your injury while waiting on a Worker's Comp.'s dispute? I just wanted to know where I stood & how serious my injury was while waiting on Worker's Comp. because it was taking forever & I was getting no where.

 

[army judge]

What if you go through your Health insurance for a second opinion on the extent of your injury while waiting on a Worker's Comp.'s dispute? I just wanted to know where I stood & how serious my injury was while waiting on Worker's Comp. because it was taking forever & I was getting no where.

You're always free to seek a second opinion.

A problem could develop regarding the payment by your insurer to the provider.

Occasionally, depending on the practitioner you visit, your claim could become complex or complicated.

You might want to consider obtaining a WC attorney.


It has to be done, seeking a second opinion that is, a certain way.
It won't interfere with the decision, it could impact payments.

Read a longer explanations about WC 2nd opinions by a TX lawyer:

Can I Get a Second Opinion in My Workers' Compensation Case?


TX WC law, not the legislative language on 2nd opinions, be very careful:

LABOR CODE CHAPTER 408. WORKERS' COMPENSATION BENEFITS






....
(f-2) An employee required to be examined by a designated doctor may request a medical examination to determine maximum medical improvement and the employee's impairment rating from the treating doctor or from another doctor to whom the employee is referred by the treating doctor if:
(1) the designated doctor's opinion is the employee's first evaluation of maximum medical improvement and impairment rating; and
(2) the employee is not satisfied with the designated doctor's opinion.
(f-3) The commissioner shall provide the insurance carrier and the employee with reasonable time to obtain and present the opinion of a doctor selected under Subsection (f) or (f-2) before the commissioner makes a decision on the merits of the issue.
(f-4) The commissioner by rule shall adopt guidelines prescribing the circumstances under which an examination by the employee's treating doctor or another doctor to whom the employee is referred by the treating doctor to determine any issue under Subsection (a), other than an examination under Subsection (f-2), may be appropriate.
(g) Except as otherwise provided by this subsection, an injured employee is entitled to have a doctor of the employee's choice present at an examination requested by an insurance carrier under Subsection (f). The insurance carrier shall pay a fee set by the commissioner to the doctor selected by the employee. If the injured employee is subject to a workers' compensation health care network under Chapter 1305, Insurance Code, the doctor must be the employee's treating doctor.
(h) The insurance carrier shall pay for:
(1) an examination required under Subsection (a), (f), or (f-2), unless otherwise prohibited by this subtitle or by an order or rule of the commissioner; and
(2) the reasonable expenses incident to the employee in submitting to the examination.
(i) An employee who, without good cause as determined by the commissioner, fails or refuses to appear at the time scheduled for an examination under Subsection (a) or (f) commits an administrative violation. An injured employee may not be fined more than $10,000 for a violation of this subsection.
(j) An employee is not entitled to temporary income benefits, and an insurance carrier is authorized to suspend the payment of temporary income benefits, during and for a period in which the employee fails to submit to an examination required by Subsection (a) or (f) unless the commissioner determines that the employee had good cause for the failure to submit to the examination. The commissioner may order temporary income benefits to be paid for the period for which the commissioner determined that the employee had good cause. The commissioner by rule shall ensure that:
(1) an employee receives reasonable notice of an examination and the insurance carrier's basis for suspension; and
(2) the employee is provided a reasonable opportunity to reschedule an examination for good cause.
(k) If the report of a designated doctor indicates that an employee has reached maximum medical improvement or is otherwise able to return to work immediately, the insurance carrier may suspend or reduce the payment of temporary income benefits immediately.
(l) A person who makes a frivolous request for a medical examination under Subsection (a) or (f), as determined by the commissioner, commits an administrative violation.

.....

 

[ElleMD]

The links above are good information but can be a bit to weed through. Couple of questions:

1. Has your claim been reported to the WC carrier?

2. Is your employer one which has opted out of WC?

3. What and when was your injury?

4. Have you seen a doctor for this? It sounds like you have, but it is unclear if you are in treatment or just had the injury checked out and are looking to reopen.

5. Has your claim been deemed compensable? In other words, are they (WC insurer or employer) disputing the injury or that the injury is work related?

6. What specifically are you looking for at this point? A second opinion to find out treatment options? A diagnostic test? Don't like the first doctor you saw and want to see someone else?

7. Has #6 been reported to your employer/insurer for authorization?