What factors are considered when determining the actual medical expenses covered by workers' compensation?

When it comes to the medical expenses covered by workers' compensation in Texas, the key factors considered are:

1. Relatedness to the Work Injury:

   • The medical treatment and expenses must be directly related to the work-related injury or illness.

   • The insurance carrier will review the medical documentation to ensure the treatment is necessary and appropriate for the work injury.

2. Reasonableness and Necessity:

   • The medical care and services provided must be considered reasonable and necessary for the proper treatment of the work-related injury.

   • This is assessed based on established medical treatment guidelines and the opinions of the treating doctor.

3. Provider Network:

   • Texas has a workers' compensation health care network system, which means the insurance carrier may require you to receive initial treatment from a provider within their approved network.

   • After the initial visit, you have the right to choose your own treating doctor.

4. Fee Schedules:

   • The Texas Department of Insurance sets fee schedules that limit the maximum amounts the insurance carrier will pay for various medical services and treatments.

   • Providers are prohibited from balance billing you for any amounts above the fee schedule.

5. Medical Necessity Disputes:

   • If the insurance carrier denies coverage for a particular treatment or service, you have the right to dispute the decision through the state's administrative dispute resolution process.

It's important to note that the medical expenses covered are not subject to the same minimum or maximum average weekly wage thresholds that apply to income replacement benefits. The focus is on ensuring the injured worker receives the necessary and appropriate medical care related to the work-related injury, regardless of their pre-injury earnings.

Working closely with your treating doctor and, if needed, an experienced workers' compensation attorney can help ensure you receive the full scope of medical benefits you're entitled to under the Texas system.