Is Your Doctor Sabotaging Your Workers' Compensation Claim?

I have been practicing workers' compensation law here in Abilene, Texas for several years, now. During that time, I've noticed several trends that never seem to go away. Here is one situation that I have seen repeat itself over and over again:

An employee gets injured at work and is promptly taken to the hospital or minor emergency clinic for treatment. They complain to the ER doctor about two problems - maybe a bad back and a sore ankle, just to take an example. For whatever reason, however, the ER personnel focus completely on the ankle. Possibly because it is the main source of pain at the moment.

It takes the insurance company a few days to respond and get the employee set up with a permanent, treating doctor. During that time, the back pain gets worse and worse, as the ankle slowly gets better. Eventually, after waiting through several more days of excruciating back pain for an appointment, the day of the employee's first appointment with the treating doctor arrives. The doctor comes into the room and asks about how the ankle is doing. They want to look at the ankle and talk about how it is so much better now.

"But Doctor," the employee says, "My back is still killing me! What about my back?"

The doctor looks at their chart with puzzlement. "No, there is nothing about the back here," they say.

"But can you treat me for the back? It is really hurting!"

"Oh, no. I can't do that. The insurance company won't pay for that. You'll need to see another doctor using your own insurance for that."

The employee then walks out, frustrated, because the (now) main source of their problem hasn't been addressed at all.

What is happening in this situation is that the insurance company has reached out to the doctor in advance of the appointment and indicated that the doctor will be treating an ankle injury. Perhaps this is because they didn't carefully review the emergency room records to see that the employee also had a back injury. Perhaps it is because the adjuster decided that back injury wasn't serious and should have healed by now, or that it was a preexisting condition.

In a situation like this, a good treating doctor will immediately report to the insurance company that - in addition to the ankle injury, the employee also has a back injury. They will seek approval for the treatment of the back as well. Sometimes, the insurance adjuster will push back at this, refusing to allow treatment for the new condition or by making the doctor or their staff document the file more extensively.

All this red tape costs the doctor time and money and, some doctors, knowing that it can be a struggle for them and their staff to get the insurance company to pay for injuries that aren't accepted by the insurance company, just give up before they even try. It is the path of least resistance.

Most of these doctors are not malicious about this. They are well-intentioned, and just believe that the injuries that haven't been accepted by the insurance company should be treated by some other part of the system. They have families and other patients to treat, and it seems just as easy to them to pass you along to a doctor who takes private insurance for your other problems. But many employees don't have the money or private insurance to pay for the treatment. Workers' compensation is their only option to get some treatment and relief of the pain.

Worse yet, the situation tends to snowball. The longer the employee goes without treatment, or even a record, of a serious injury, the more skeptical the insurance company will be about whether the injury is related to the accident. Later down the road, when the case goes in front of an administrative judge, the insurance company will point do your doctor's records and talk about how you "didn't make a complaint" to your doctor about your back. They will then ask the administrative judge to conclude that the back problems must have come up much later after the accident when - in fact - you had been complaining, but they had just been refusing to listen to you.

Intentional or not, the effect when a doctor doesn't take your complaints seriously is to sabotage your workers' compensation claim, often in ways that can't be repaired down the road.

If you find yourself in a situation like this, your best option is often to ask for a new treating doctor. If you have a doctor who you don't believe will go to bat for you against the insurance company, you are going to have all kinds of problems down the road. Ask around, and try to find a doctor who will listen to your problems and push back when the insurance company disagrees with their judgment.

Failing that - and it is often the case that finding a new treating doctor is harder than it ought to be - you probably need legal help. You should seek out a lawyer who practices workers' compensation in your area. If you can't find one that will take your case, at least reach out to the DWC's Office of Injured Employee Counsel. The Ombudsmen there are not lawyers and don't "represent" you like a lawyer would, but they can help to point you in the right direction.

In no event, however, should you ignore this warning sign. If your doctor says that they won't treat a condition because "the insurance company won't pay for it" - and they aren't even trying to get approval to get it paid - your claim is heading in a bad direction.