Getting Medication After Claim Closure

By Jason Weinstock on September 22, 2010


Prescription-BottlesWhen the adjuster sends a letter, either scheduling a rating evaluation, or simply closing the claim, No additional medical treatment will be authorized.  That means that the insurer will also stop paying for any medication refills, and will not authorize return visits to the doctor for more medication.  If the injured worker’s treating doctor reports that the patient will need ongoing medication, then this issue needs to be discussed and resolved with the adjuster before the appeal time (70 days) runs on claim closure.  Additionally, if an injured worker accepts a permanent partial disability award in a lump sum, any appeal the injured worker has filed on claim closure to obtain ongoing medication will be dismissed.

Nevada statutes and regulations governing workers’ compensation claims do not address what the insurer’s obligations are to provide ongoing medication after the treating doctor recommends that that claim be closed. The best way to deal with this issue is to negotiate with the adjuster to reach a reasonable agreement.  Assuming the treating doctor makes it very clear that ongoing medication is necessary, many insurers are willing to pay for medication for at least a year after the claim is closed and are agreeable to letting the injured worker receive his PPD award also. Insurers are usually only willing to do that when the injury is very serious.  If the insurer agrees to ongoing medication for a year, the insurer will want to make a new determination after a year after asking the doctor whether more ongoing medication is necessary. 

Other insurers take a more obstinate stance and refuse under any circumstances to pay for any medication or doctors’ visits after claim closure. The injured worker can appeal the claim closure letter, and try to persuade a hearings or appeals officer  to order the insurer to provide ongoing medication.  While it is possible to obtain such an order, the problem is that this appeals process takes months.  Again, the injured worker can not take his permanent partial disability award in a lump sum while the claim closure/medication issue is being litigated.  Many injured workers cannot afford to let their award money sit with the insurer while trying to get ongoing medication through the appeals process.

Obtaining ongoing medication after claim closure is difficult, and most injured workers will be unable to obtain it without an attorney.  If the injured worker is able to obtain it without an attorney,  it is essential that any agreement obtained from the adjuster be in writing.  Adjusters change frequently, and an oral agreement will not be enforceable.