What is the difference between Workers’ Compensation and Health Insurance, and Which Should I Use?
Compare Workers’ Compensation and Health Insurance for work related disability claims. Learn which should you use and when you should use them.
If an accident or a disease associated with your workplace strikes your life, you will have many things to consider. One of the high priority items is to know who is going to pay for the medical bills that are about to start rolling in. This is especially important if you have a work-related disability claim. If you are covered by both workers’ compensation insurance and your own health insurance, you want to understand which to use.
Normally, if you have an accident or suffer from a disease that is work-related, your first stop is to depend on the workers’ compensation program, not your health insurance. As long as your employer is providing workers’ compensation coverage, and your claim is directly related to an illness or injury at work, your employer will pay those expenses through the workers’ comp program. Once the workers’ compensation board approves your application, these medical bills will be paid by that plan. This should cover all your necessary and reasonable medical expenses related to such an injury or disease.
There is another consideration. When you take the workers’ compensation benefits, you must allow access to your medical records as it pertains to this injury or illness or anything work-related. This is to verify that you qualify, and continue to qualify for workers’ comp benefits.
It is possible your employer also provides health insurance for you and your family, or you may have subscribed to a private health insurance policy on your own. Private health insurance is not the same as workers’ compensation; it is a completely different program. It is not meant to compete with or replace workers’ compensation. In fact, some health insurance companies specifically state their insurance will not cover work-related claims.
Use your private health insurance for your personal medical needs outside your workplace. For example, if you catch the flu or fall and get hurt in or around your home and need to visit your doctor, a clinic or hospital, use your private health insurance.
If you use your private health insurance instead of workers’ comp for a work-related accident, your medical records remain private but your deductible, co-payments, and out-of-pocket expenses will not be reimbursed to you and your lifetime benefit limit spelled out in your insurance policy will apply. If your accident or illness is work-related and turns out to be a long-term or lifetime disability, your personal insurance may eventually run out.
In other words, if you suffer from a serious accident in your work environment, for instance, and expect to be out of work for over a year, or maybe not return to work ever, all the medical expenses could fall under the workers’ comp program. This might include diagnosis, treatment, medications, surgery, hospitalization, or even long-term rehabilitation or care involving nursing. Prosthetic devices, dental treatment, glasses, wheelchairs, or even hearing aids might come under this coverage, as long as it is related to the workplace injury. There are no deductibles or co-payments, and there is no cap on a maximum amount of claims. However, your employer will have access to your medical records to assure that you are diagnosed with a work-related illness or injury, that you are getting treatment, and that you are truly unable to return to work or only work in a limited capacity.
If your employer provides workers’ compensation but tells you that you must use your own health insurance for a work-related injury, you should contact the workers’ compensation board in your state yourself for clarification, as that request is not the normal procedure. If necessary, you could use your own private health insurance in the meantime.
By using your own health insurance to pay for such medical bills, you are running the risk of having to pay them later from your own personal funds. If the health insurance pays for such medical bills, and you later win a workers’ comp claim, the health insurance company will require reimbursement from you for the amounts they already paid. Nonetheless, if your employer is refusing to pay a work-related injury claim, you can use your medical insurance while you appeal the workers’ comp denial or while you take your case to the civil court system.
If your employer terminates your employment because your job is no longer needed or because you are unable to work with such an injury, there is a federal law called COBRA, (Consolidated Omnibus Budget Reconciliation Act of 1985), which ensures you won’t lose all your health care coverage immediately. It lasts for up to 18-months and allows you to continue your group health insurance coverage; however, all the insurance premiums must be paid by you. This makes this option expensive, but at least you have the option to have continuous coverage. It might also be possible to continue your company’s health insurance coverage because of a union or employment contract.
If your workers’ compensation claim is denied, and you have proof that your illness or injury is work related, you should see an attorney who has specialized training and experience in this area to protect yourself. Also, seek such advice if you are trying to decide whether you should keep your medical records private or not.
To recap: Remember, workers’ comp and your health insurance are two different plans.
If you have suffered an injury or a disease that is work-related and workers’ comp covers you, expect them to pay for all necessary and reasonable medical expenses connected with the claim. If workers’ comp denies your claim, you can use your health insurance while you appeal the workers’ comp denial or take your case to the civil courts. Use personal health insurance if you are injured outside of work, or if your job is not covered by workers’ compensation insurance.