On The Job Injuries

Medical, Hospital & Surgical Benefits

INTRODUCTION TO MEDICAL BENEFITS UNDER OKLAHOMA LAW

Medical, hospital, & surgical benefits are the core benefits of the Oklahoma Workers Compensation system. All other benefits and workers comp settlements in the case are dependent and are in no small way maximized based upon an injured Tulsa or Oklahoma City injured worker &/or his or her lawyer or attorney demanding and then going forth & receiving proper medical care & surgery.* For example, the Oklahoma Work Comp Law severely limits an injured employee’s receipt of both a permanent settlement award & weekly cash benefits based upon how his or her injury is MEDICALLY defined & otherwise described. As such it is absolutely imperative for an injured Oklahoma City or Tulsa area employee &/or his or her attorney or lawyer to carefully obtain his or her medical benefits within the strict confines of the Oklahoma Workmans Compensation Court. It should be understood that an injured worker’s employer &/or its insurance company will work diligently to thwart his or her efforts to obtain proper medical treatment and will instead attempt to direct his or her medical treatment through its own set of doctors (i.e. “company doctors”) and medical providers in an attempt to minimize the amount of money and benefits ultimately paid on the claim. To make sure you end up with the benefits to which you are entitled, consult with our Oklahoma disability lawyers.

*In fact–the Oklahoma Workers’ Compensation Act provides that: “there shall be a rebuttable presumption in favor of the treating physician’s opinions on the issue of temporary disability, permanent disability, causation, apportionment, rehabilitation or necessity of medical treatment”

SCOPE OF MEDICAL & SURGICAL BENEFITS UNDER OKLAHOMA LAW

Generally and at the outset it should be noted that Oklahoma Workers’ Compensation medical benefits are unlimited in both duration and amount. Consider the following:

There is no arbitrary or preset limit in the Oklahoma Workmans Comp Court rules that specifically limits the amount of time (i.e. years, months, weeks) that an injured Tulsa or Oklahoma City employee or worker can receive medical treatment or benefits. In fact, it is not uncommon for an injured Oklahoma Workmens Compensation claimant to receive lifetime medical care under Oklahoma law.
There is no statutory cap on the monetary amount (i.e. thousands of dollars) that an Oklahoma employer or its insurance company can be forced to pay for an injured employee’s medical care and treatment. In fact, some injured Tulsa & Oklahoma City area workers receive medical, surgical and hospital benefits that total in the seven or even eight figure range over the life of their case.

INJURED EMPLOYEE NOT RESPONSIBLE FOR ANY EXPENSES RELATED TO HIS OR HER MEDICAL TREATMENT: Oklahoma City & Tulsa Workmens Comp Court rules are strict and impose severe penalties upon an Oklahoma employer &/or its insurance company who attempt in any way to impose any financial obligation upon its injured worker to pay any part of his or her medical expenses related to an on-the-job injury. Simply put–Oklahoma City and Tulsa Workers Compensation clients are not obligated to pay any type of co-pay, deductible, or even be subjected to any kind of waiting or elimination period to obtain Oklahoma Workers Comp medical treatment. Furthermore, Oklahoma City & Tulsa Work Comp Court rules are firm inthat any monetary deficiency between what a medical provider receives under the Oklahoma Workmans Compensation fee schedule and the provider’s usual charge cannot be collected from the injured employee–severe penalties exist against a medical provider attempting to collect medical expenses of a workmans comp injury from the injured worker himself or herself.

WORKMENS COMPENSATION MEDICAL BENEFITS vs. EMPLOYER PROVIDED HEALTH INSURANCE COVERAGE: As is obvious from the above discussion–there is a huge difference between an injured worker receiving medical care and treatment under the employer’s & employee’s health insurance plan, which may have significant limits on the amount and duration of care, as well as deductibles, co-pays, and waiting periods, and Oklahoma Workmens Comp medical & doctor’s benefits, where no such treatment limits and financial burdens apply. Considering this–it should not be surprising that, following a job-related injury, many Oklahoma employers &/or their insurance companies, attorneys and lawyers strongly “encourage” their injured Oklahoma City and Tulsa area employees to simply file a claim and receive medical treatment under their own health insurance instead of filing for Oklahoma Workers Compensation benefits–implying either directly or indirectly that the medical benefits and treatment received under both systems are somehow comparable, when they clearly are not.*

*In addition to Oklahoma Workers Comp medical benefits being preferable to treatment received under an injured employee’s health insurance plan, it should also be noted that the Oklahoma Work Comp system provides a weekly check during the injured Tulsa or Oklahoma City workers’ healing period as well as a Workmans Compensation permanent disability award or cash settlement at the end of his or her case–which health insurance clearly does not.

With the above general principles of the Oklahoma Workmans Comp medical benefits system in mind, the Tulsa or Oklahoma City injured worker &/or his or her attorneys or lawyers should consider the following specific rules and procedure followed by the Oklahoma City and Tulsa Workmens Compensation Court in administering medical care and treatment in Oklahoma:

INITIAL MEDICAL TREATMENT TO BE PROVIDED BY EMPLOYER

The Oklahoma Workmens Comp Court rules mandate that all employers and their insurance companies PROMPTLY provide injured Oklahoma City and Tulsa area workers with such medical, surgical or other attendance or treatment, nurse and hospital service, medicine, crutches, and apparatus as may be necessary after the injury. At the outset the employer’s or employer’s attorney or lawyer’s selected physician or doctor (i.e. the ‘company doctor’) shall have the right and responsibility to treat the injured employee. However, if the employer fails or neglects to so provide medical treatment to the injured Oklahoma worker within three (3) days after knowledge of the injury is received by the employer, the injured employee, his or her attorneys or lawyers, during the period of such neglect or failure, can select a physician or doctor to provide medical treatment at the expense of the employer &/or its insurance company. However, once the employer has selected a treating physician &/or doctor and has offered the injured Oklahoma City or Tulsa employee treatment, the physician or ‘company doctor’ selected by the employer or its Oklahoma Workers Compensation insurer shall become the treating physician for the injured worker’s on-the-job injury.

TO BE SURE–Upon notice that an Oklahoma City or Tulsa area employee has sustained an on-the-job injury, the employer &/or its insurance company has a clear obligation under the Oklahoma Workers Comp law to provide that injured worker with reasonable and necessary medical treatment. Furthermore, Oklahoma Work Comp Law unequivocally states that it is absolutely not necessary for there to be any type of order, judgment or award of either the Tulsa or Oklahoma City Workmans Compensation Court directing the employer to provide these medical benefits before doing so–they are due immediately and by operation of law.

EMERGENCY TREATMENT UNDER OKLAHOMA WORK COMP LAW

An injured Tulsa or Oklahoma City worker, or another in the injured employee’s behalf, to include his or her attorneys or lawyers, may arrange and obtain emergency treatment for the hurt employee at the expense of the employer–where such emergency treatment is not provided by the employer or its insurance company. To be clear–prior approval and authorization from the employer &/or its insurance company is absolutely not a prerequisite or necessary for an injured worker to go forth and receive emergency medical treatment from a doctor or other medical provided under Oklahoma Workmans Comp law.

OK CERTIFIED WORKPLACE MEDICAL PLANS (CWMP)

If an Oklahoma employer or the employer’s Workmens Compensation insurance company has previously contracted with a CERTIFIED WORKPLACE MEDICAL PLAN (CWMP), such employer shall select for the injured Oklahoma City or Tulsa worker a treating physician or doctor from the physicians listed within the network of the certified workplace medical plan to provide medical care & treatment to an injured employee under the Oklahoma Workers Compensation Act. Thereafter the injured claimant or his or her lawyer or attorney may apply to the certified workplace medical plan for a one time change of physician to another appropriate physician within the network of the certified workplace medical plan by utilizing the dispute resolution process set out in the certified workplace medical plan. Oklahoma Workmens Comp Court rules require the dispute resolution procedure of the plan to include a requirement that disputes related to medical care under the plan, including a subsequent change of physician, be resolved within ten (10) days of the time the dispute arises and if not resolved within ten (10) days, the injured Oklahoma City or Tulsa employee or his or her lawyer or attorney may pursue remedies in the Oklahoma City or Tulsa Workers Compensation Court. To be clear–an injured worker or employee shall exhaust the dispute resolution procedures of the certified workplace medical plan before the worker or his or her attorneys or lawyers may seek legal relief on an issue related to medical care under the plan, including a subsequent change of physician, provided the dispute resolution procedure shall create a process which shall attempt to resolve the dispute within ten (10) days of the time the dispute arises and if not resolved within ten (10) days, the employee may pursue remedies in the Tulsa or Oklahoma City Workers Comp Court.

Oklahoma Work Comp law provides that nothing shall preclude an injured Oklahoma employee (or his or her attorneys or lawyers), who has exhausted the dispute resolution process of the certified workplace medical plan, from petitioning the Tulsa or Oklahoma City Workmans Compensation Court for a change of treating physician within the certified workplace medical plan or, if a physician who is qualified to treat the worker’s injuries is not available within the plan, for a change of physician outside the plan. However, Oklahoma Workmans Comp law is clear that disputes relating to treatment provided or to be provided through a certified workplace medical plan, including requests for a change of physician within the plan, shall be timely processed through the internal dispute resolution procedures of the certified workplace medical plan prior to pursuing remedies in the Tulsa Workmens Compensation Court.

NOTE: A certified Workplace Medical Plan must provide authorization for necessary emergency medical treatment for an injury provided by a provider of medical, surgical, and hospital services who is not part of the plan. Furthermore–any certified workplace medical plan must provide medical treatment required by the Oklahoma Workers’ Compensation Law in a manner that is timely, effective and convenient for the injured worker and carries out the intent of the Workers’ Compensation Act.

NOTE: Although it is the policy of the Tulsa & Oklahoma City Workmens Comp Courts to encourage insurance companies, injured workers, attorneys & lawyers to use alternative dispute resolution procedures such as mediation and settlement conferences for the early disposition of pending litigation, disputes related to medical care under a certified workplace medical plan are specifically excluded from the Court’s comprehensive mediation program.

INJURED WORKERS’ RIGHT TO SELECT OR CHANGE PHYSICIAN

As described in more detail elsewhere on this page, where the injured Tulsa or Oklahoma City area employee is not covered by a certified workplace medical plan (CWMP), the employer by Oklahoma Workers Compensation law has the initial right if not obligation to select and otherwise designate the treating physician or doctor to treat the injured worker (generally called or referred to as the ‘company doctor’). However thereafter, the Tulsa or Oklahoma City Workers Comp Court upon application of the injured employee, his or her lawyers or attorneys, shall order a one-time only change of treating physician. The treating doctor so chosen will be and is referred to as the “FORM A doctor”.

PROCEDURE FOR SELECTING FORM A DOCTOR: In the event the injured worker, his or her attorney or lawyer makes proper application for such a change of physician, the employee or his or her attorney or lawyer shall list on such application the name of the injured employee’s current treating doctor, the body part for which a change of physician is sought, and a list of three proposed physicians who are qualified to treat the injured body part affected and named. The employer &/or insurance company thereafter shall choose or otherwise agree to one of the physicians or doctors listed by the employee, his/her attorney or lawyer or submit its own list of three (3) physicians or doctors. If the injured worker/employee and his or her attorney or lawyer on the one hand, and the employer/insurance company on the other, cannot agree on a physician from among the doctors named by the parties, the Tulsa or Oklahoma City Work Comp Court, as the case may be, shall appoint or select from the list of independent medical examiners maintained by the Oklahoma Workmans Compensation Court a treating physician who is qualified to treat the body part(s) affected and who can see the injured employee within a reasonable time.

NOTE: A Form A change of physician shall be allowed for each individual body part injured if the treating physician determines that the worker’s injured body parts cannot be treated by the same physician.

COURT APPOINTED INDEPENDENT MEDICAL EXAMINATIONS (CIME)

Disputes regarding an injured Tulsa or Oklahoma City area worker’s need for medical treatment, the cause of his or her medical condition, questions regarding whether the injured employee can return to work or is otherwise temporarily and totally disabled, the nature and extent of his or her injury (or permanent partial disability), whether he or she is permanently and totally disabled, as well as other issues relying upon an appropriate medical opinion, can be resolved in whole or in part by the appointment of an independent medical examiner from the Oklahoma Workmans Comp Court’s list of independent medical examiners. Appointments shall take into account the specialty, availability and location of the examiner.

A request for an Court Appointed Independent Medical Examination (“CIME”) can be made by motion of any party to the case, including the employer, its insurance company, attorneys, or the claimant &/or his or her lawyers. The Oklahoma City or Tulsa Workmens Compensation Court, upon its own motion, may appoint a CIME as well and as it sees fit. If the parties fail to agree on the selection of an independent medical examiner, the Court shall randomly select an independent medical examiner who shall be afforded a reasonable opportunity to examine the employee together with all medical records involved and any other medical data or evidence that the independent medical examiner may consider to be relevant. The independent medical examiner shall issue a verified written report to the Court stating his or her finding on the percentage of permanent impairment of the employee and whether or not the impairment is job-related and caused by the accidental injury or occupational disease.

In the event the independent medical examiner determines that more medical treatment is necessary or in the event the treating physician refuses to treat, the employer shall designate a treating physician to provide the indicated treatment–all as more fully described above.

NOTE: The independent medical examiner cannot provide treatment to the injured worker whose claim the independent medical examiner has reviewed for permanent impairment, return to work, or the necessity of further medical treatment, unless both employee and employer agree through written stipulation and said stipulation occurs prior to the appointment, referral and notice to said independent medical examiner.

NOTE: In order to be eligible for appointment, a qualified independent medical examiner in a case involving permanent disability shall not be a treating physician of the injured employee or have treated the hurt employee with respect to the injury for which the claim is being made or the benefits are being paid.

WORKERS’ COMPENSATION CASE MANAGEMENT

For Oklahoma Workmens Comp cases not covered by a certified workplace medical plan (CWMP), and where the insurance company does not voluntarily provide medical case management, case management may be granted or ordered by the Tulsa or Oklahoma City Workers Compensation Court on the request of any party, including the injured worker, his or her attorney, the employer, its insuance carrier, or its attorneys or lawyers, or even when the Tulsa or Oklahoma City Workers Comp Court determines that medical case management is appropriate under the circumstances. Upon proper request the Tulsa or Oklahoma City Work Comp Court shall appoint a case manager from a list of qualified case managers developed, maintained and periodically reviewed by the Court. The reasonable and customary charges of a medical case manager appointed by the Oklahoma Workmans Compensation Court shall be bourne by the employer &/or its insurance company, not by the injured employee.

NOTE: Except in cases covered by a certified workplace medical plan, upon application of the employee, the Workmans Comp Court may order the employer to provide one change of case manager if the employee did not make the initial selection of the case manager.

REIMBURSEMENT & PAYMENT OF TRAVEL EXPENSES

Travel expenses related to an injured employee’s submission to a medical examination or incurred in obtaining reasonable & necessary medical treatment, vocational evaluations, and vocational retraining shall be paid to the hurt worker. Mileage and necessary lodging expenses are limited to the provisions of the state travel reimbursement act. Meals will be reimbursed at the rate of Eight Dollars ($8.00) per meal per four hours of travel status, not to exceed three meals per day. Travel expenses paid to the injured employee shall include only expenses for travel from the residence of the claimant at the time of the examination, treatment, evaluation or retraining, as applicable, not to exceed 600 miles round trip. Oklahoma hurt workers are currently being reimbursed their mileage at fifty cents ($.50) per mileage traveled. The employer shall not be liable for travel which is wholly within the limits of the city or town of the injured worker’s residence. Exceptions to this rule shall be at the discretion of either the Oklahoma City or Tulsa Workmens Compensation Court.

DEFENSE MEDICAL EXAMINATIONS (DME)

Upon reasonable advance notice from the employer, its insurance company &/or attorneys or lawyers, as the case may be, and upon receipt of statutory travel expenses as more fully described above, an injured Oklahoma City or Tulsa area worker must submit to a medical examination by a physician or doctor selected by the employer &/or its insurance company. These types of examinations are commonly referred to as a Defense Medical Examination (“DME”). If an injured employee refuses to submit to such an examination, the employer &/or its insurance company or attorney or lawyer may request that either the Oklahoma City or Tulsa Workmens Comp Court, as the case may be, enter an order finding that the injured employee’s compensation and right to prosecute any proceeding under the Oklahoma Workers Compensation Act be suspended during the period of such refusal. The injured worker &/or his or her attorneys or lawyers, in such case–must show good cause at the subsequent hearing or trial why the employer’s request to hold the case in abeyance should not be granted. The court, in its discretion, may assess the cost of the examination against the injured worker.

CONTINUING MEDICAL MAINTENANCE (CMM) BENEFITS

As far as an injured Oklahoma City or Tulsa area injured worker receiving ongoing & continuing medical maintenance (“CMM”), citation to the particular Oklahoma Workers Comp law dealing with the issue is worth stating verbatim:

Continuing Medical Maintenance (“CMM”) means medical treatment that is reasonable & necessary to maintain (an injured Oklahoma Work Comp worker’s) condition resulting from the compensable injury or illness after reaching maximum medical improvement (“MMI”). Continuing Medical Maintenance shall not include diagnostic tests, surgery, injections, counseling, physical therapy or pain management devices or equipment, unless specifically authorized by the (Tulsa or Oklahoma City) Workers’ Compensation Court in advance of such treatment.

The most recent changes in Oklahoma law have clamped down on continuing medical maintenance benefits and specifically provide that unless recommended by the treating doctor at the time the injured worker reaches maximum medical improvement, continuing medical maintenance shall not be awarded by the Oklahoma City or Tulsa Workmans Compensation Court unless there is clear and convincing evidence to the contrary submitted by the injured employee &/or his attorneys or lawyers. At any time during the pendency of a case, a judge of the Tulsa or Oklahoma City Workmans Comp Court, upon the judge’s own motion or at the request of any party, including the injured worker, his attorney or lawyer, or the employer or the insurance company–may appoint an Independent Medical Examiner to determine the nature and extent of continuing medical maintenance (NOTE: Appointment of a Court appointed independent medical examiner, or CIME, is discussed more fully elsewhere on this page).

DISPUTES BETWEEN INSURANCE COMPANIES RE: PAYING BILLS

Whenever two or more Oklahoma Workmens Compensation insurance companies disagree as to which insurance company shall pay for the ongoing and continuing medical care expenses of an injured Oklahoma worker &/or employee, the Tulsa or Oklahoma City Workmens Comp Court shall order one of the insurance companies to start paying for the workers medical treatment costs immediately. Any decision of the Tulsa or Oklahoma City Workers Compensation Court to chose one insurance company over another insurance company to pay for the medical treatment of an injured Oklahoma employee shall not be appealable until the Tulsa or Oklahoma City Workers Comp Court’s final order as to the permanent partial or total disability of the injured worker. The Work Comp insurance company in the final order who is liable on the risk for the on-the-job injury shall immediately reimburse the other Workmans Compensation Insurance Company for medical monies expended upon proper proof of payment.

NOTE: In all cases the Oklahoma City or Tulsa Workmans Comp Court shall have full authority to require an employer and an insurance company to reimburse other employers and insurance companies for Workmens Compensation benefits paid pursuant to the Oklahoma Workmens Comp Act in appropriate cases.

PENALTIES FOR FAILURE TO PAY MEDICAL BENEFITS UNDER OKLAHOMA LAW

the right to recover charges for every type of medical care for personal injuries arising out of and in the course ot covered employment as herein defined, shall lie solely with the Oklahoma Workers’ Compensation Court, and all jurisdiction of the other trial courts of Oklahoma over such action have been abolished. When a medical care provider has brought a claim in the Oklahoma Workers’ Compensation Court to obtain payment for services, a party who prevails in full on the claim shall be entitled to a reasonable attorney fee.

The Tulsa &/or Oklahoma City Workers Compensation Courts are fully empowered to impose upon anyone, to the total cost of any proceeding, attorney fees or other costs, against a person, attorneys, lawyers, insurance company or other party–who is determined to have unreasonably denied medical benefits.

The determination of disability shall be the responsibility of the workers’ Compensation Court. Any claim submitted by an employee for compensation for permanent disability must be supported by competent medical testimony which shall be supported by objective medical findings and which shall include an evaluation by the treating physician or an independent medical examiner if there is no evaluation by the treating physician, stating his or her opinion of the employee’s percentage of permanent impairment and whether or not the impairment is job-related and caused by the accidental injury or occupational disease. A copy of any written evaluation shall be sent to both parties within seven (7) days of issuance. Medical opinions addressing compensability and permanent impairment must be stated within a reasonable degree of medical certainty.

Any party may object to the opinion of the treating physician by giving written notice to all other parties and to the Court. Upon receipt of such notice, if the parties fail to agree on the selection of an independent medical examiner, the Court shall randomly select an independent medical examiner who shall be afforded a reasonable opportunity to examine the employee together with all medical records involved and any other medical data or evidence that the independent medical examiner may consider to be relevant. The indepenent medical examiner shall issue a verified written report on a form provided by the Administrator to the court stating his or her finding of the percentage of permanent impairment of the employee and whether or not the impairment is job-related and caused by the accidental injury or occupational disease.

There shall be a rebuttable presumption in favor of the treating physician’s opinions on the issue of temporary disability, permanent disability, causation, apportionment, rehabilitation or necessity of medical treatment. Any determination of the existence of extent of physical impairment shall be supported by objective medical evidence.

The Independent Medical examiner shall be allowed to examine the claimant, receive any medical reports submitted by the parties and review all medical records of the claimant. If the independent medical examiner determines that the opinion of the treating physician is supported by the objective medical evidence, the independent medical examiner shall advise the court of the same. If the independent medical examiner determines that the opinion of the treating physician is not supported by objective medical evidence, the independent medical examiner shall advise the court of the same and shall provide the court with his or her own opinion. In cases in which an independent medical examiner is appointed, the court shall not consider the opinion of the independent medical examiner unless the independent medical examiner determines that the opinion of the treating physician is not supported by objective medical evidence, in which case the court shall follow the opinion of the independent medical examiner, the opinion of the treating physician or establish its own opinion within the range of opinions of the treating physician and the independent medical examiner. if the court does not follow the opinion of the treating physician, the court shall set out its reasons for deviating from the opinion of the treating physician.

Any party may request the deposition testimony of the treating physician or the independent medical examiner providing a written medical report on the issue of temporary disability, permanent disability, causation, apportionment or rehabilitation. The party requesting the deposition testimony of any such physician shall be responsible for the reasonable charges of the physician for such testimony, preparation time, and the expense of the deposition

NOTE: Benefits for an injury shall be determined by the law in effect at the time of injury.

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