When a worker's compensation claim is denied, an injured worker in Wisconsin can incur significant medical bills. Those medical bills may be paid by the worker's group health insurance, by the worker themselves, or just remain outstanding. Under Wisconsin law, an injured worker can seek reimbursement for the medical bills paid out of their own pocket.
Health Insurance Payments
Many employee claims for medical expenses will be paid by health insurers, even if the injuries are work-related and should be paid by the worker’s compensation insurance carrier. In some instances, the health insurer pays because it does not realize the accident or disease was work-related, and in other cases, the claims will be paid by the health insurer because the worker’s compensation carrier disputes that the injury was work-related (or the employer directs the employee to file the claim under the health insurance policy). In either case, the health insurer has the right to recoup the payments, because health insurance policies exclude payments of medical expenses covered by the worker’s compensation carrier. While the group health carrier is prohibited from intervening in worker’s compensation proceedings, the department may direct reimbursement by the worker’s compensation insurer for payments made by health insurance carriers, when the department finds a work-related injury.
Additionally, if an injured worker pays for any work-related treatment of out of their own pocket (co-pays, prescriptions, mileages), they absolutely are entitled to be reimbursed if the claim (and resulting treatment) is deemed work-related. An application for hearing, with the assistance of an attorney, generally is necessary. Reimbursement can occur through either a settlement or prevailing at a court hearing.
As medical expenses now eclipse indemnity (or actual compensation dollar) benefits in Wisconsin worker’s compensation claims, reimbursement for past medical expenses can be a significant issue—and drive the need for many cases and the need for representation