August 19, 2019

Can Insurance Company Deny Treatment for Medication Side Effects?

Recently I had to handle a situation for a client when the workers’ compensation insurance company denied treatment for migraine headaches caused by medication given to my client by an authorized physician.

In this case, my client hurt his back badly about a year previously when he was lifting HVAC equipment.  For several months, the insurance company fought us in our attempt to get proper medical treatment but eventually I was able to get him to a good doctor who scheduled him for surgery to repair a large herniated disc in his lumbar spine.

Post surgery, my client developed complications when fluid began to build up in the spinal canal.  The surgeon prescribed a strong medication to help drain the fluid and prevent an infection.  Unfortunately this strong medication resulted in migraine headaches.

Although the migraine headaches were new, the law in Georgia is clear that medical treatment and medications necessary to treat a complication from a compensable injury is also compensable and must be paid for by the insurance company.  And, in fact, the insurance adjustor originally assigned this case, authorized my client’s pharmacy to dispense his migraine medication

Several weeks into the treatment regimen, a new adjustor was assigned to this claim.  The new adjustor decided that the migraine headaches were not related to the work injury and she canceled the pharmacy authorization.  Suddenly, my client was left without medication to treat his frequent and painful migraine headaches.

As you might imagine, this development left my client in a great deal of pain.  I immediately got on the phone with the adjustor but she would not change her position.  I then wrote the treating doctor to request a statement from him that “connected the dots” and related the migraine headaches to the original work injury.   I also got on the phone to the defense attorney representing the employer/insurer to demand that my client’s prescription be approved.  It took about 5 phone calls until I finally got the defense attorney to call me back – he acknowledged that our position was correct and he was able to convince the adjustor to start the medication authorization again.

This type of arbitrary action by workers’ comp insurance adjustors is all too common.  Adjustors come and go and a reasonable, knowledgeable insurance claims person can be replaced by someone new who is inexperienced, stubborn or even vindictive.  As a claimant’s lawyer, I make every effort to stay on top of problems like the one my client experienced and to take whatever steps are necessary to solve these problems.