Who pays for medical expenses if the claim is deferred?
No one should pay for medical expenses while the claim is in a deferred status. If SAIF accepts the claim, we will pay for medical care related to the claim. If the claim is denied, the worker or the worker’s private health insurance carrier will be responsible for medical expenses. However, as of January 1, 2002, a claim that is denied and is on appeal will be processed by the health insurance company, provided the worker has coverage. However, if there is a balance remaining, the medical provider can bill the workers compensation carrier, who will pay up to the fee schedule for certain types of medical services prescribed to reduce pain, diagnose the condition or prevent disability. If the claim denial is ultimately upheld, the amount paid to the medical provider can be held as an overpayment and deducted from future worker’s compensation benefits with the same insurer.
