Reopening Rights. Opening the door to more treatment after your workers compensation claim has been closed.
Jane injures her back injury while working for the one of the big Casinos on the Strip. She goes through the workers’ compensation system, receives a settlement at the end of the case, and her case closes. A few months later, the pain worsens in her back and she wants to see the doctor she was seeing under her workers compensation case. Can she return to her doctor and get some additional treatment, now that he case has closed?
I get asked this question often by my clients: What happens if I need more treatment after my workers compensation claim closes? Do I have to pay for it? Does workers compensation insurer pay or can I see a doctor through my health insurance?
Don’t assume that the workers compensation insurer will simply pay for additional treatment after the closure of the claim, simply because it’s related to your work injury. After the insurer closes a workers compensation claim, an injured worker must obtain prior approval from the workers compensation insurer before the insurer will pay for medical treatment, or anything else relating to the claim. There is a process for doing this. In Nevada, to get approval from workers compensation for additional treatment after the workers’ compensation claim has closed, you must go through the process outlined in NRS 616C.390 to “reopen” your claim for further treatment.
The process outlined in NRS 616C.390 requires, among other things, that you have a report from a doctor stating that your medical condition has worsened since the date of the claim closure, that your worsening condition is related to the original work injury, and a recommendation for further treatment for your injury.
Generally, an injured worker in Nevada only has lifetime reopening rights to get additional treatment if the injured worker received a permanent partial disability settlement, or was taken off of work during the original claim because of the work-related injury.
Also, different burdens apply if the injured worker decides to request reopening within a year of the claim closing versus waiting a year. In general, it easier for the injured workers to successfully reopen a claim after the one-year anniversary of the claim closing. So, it is better to wait at least a year before trying to get more treatment.
If the injured worker did not receive a permanent partial disability settlement or was not taken off of work in the original claim, then the injured worker does not have lifetime reopening rights. In this scenario, the injured worker must request reopening within a year of the claim closure. After the one-year anniversary, the injured worker no longer has the right to request reopening of their claim.
Also, if the workers compensation insurer paid less than $800.00 in medical costs for the injured worker’s claim, then the injured worker is not entitled to reopening.
Practically speaking, the most important thing to do for an injured worker who has lifetime reopening rights and wants to obtain more treatment by reopening their claim is to obtain a strong medical report from a doctor supporting the medical necessity of reopening the claim. As stated above, this report must say that the work injury has worsened and that more treatment is needed.
Beware. The insurer usually will not pay for this medical examination and the injured worker generally must come out of pocket to obtain the report before requesting reopening.
Even with a good reopening report from a respected doctor, don’t be surprised if the insurer denies the request for reopening. Workers compensation insurer’s vigorously defend reopening requests. If this occurs, then the injured worker has the right to file an appeal and fight to reopen the claim through the administrative appeals process.