Here’s an inquiry we received that I thought people might find interesting.

I hurt my knee at work and was eventually diagnosed with a torn anterior cruciate ligament, ACL injury. I had surgery that the workers’ compensation insurance company paid for. I’m half way through my post surgery physical therapy process. I showed up to PT today and the therapist told me that the adjuster said they were no longer going to pay for my sessions. Any idea why and what I can do?

The answer I gave was that I needed to talk to them to learn more, but even before that happened, there were a variety of reasons this could have happened. Here are some of them:

  1. The insurance company got new information that gave them a reasonable belief that the injury wasn’t work related. That could be something like a tipster calling up and saying that you actually hurt yourself when you slipped on ice in your own driveway, not at work. Or it could have been a social media post that indicates you are lying.
  2. They came across medical records that contradict how you got hurt.
  3. An IME or records review doctor stated that additional physical therapy isn’t needed. That would be odd as in most cases PT starts within two weeks of the surgery and is expected to last 4-6 months. That said there are plenty of doctors for hire who would state whatever the insurance company wants.
  4. They don’t think the physical therapy office is legit. Most places are, but there are some doctors who run it out of their office schedule more therapy than is medically necessary or even get caught billing for work that doesn’t take place.
  5. The insurance company is messing with you. They will do this. If they think that you won’t do anything about it or that you’ll just put the treatment through your own insurance, they’ll cut off your benefits to save some money. It’s gross, but it happens a lot.
  6. They made a mistake. Believe it or not, this could have been someone at the PT office calling for treatment approval and somebody mistakenly saying it’s not authorized.

If you watched the most recent season of “True Detective,” Jody Foster’s character frequently says, “You are asking the wrong question.” That’s what’s happening here. The right question is, “How do we solve this problem so the injured worker can get the physical therapy they need and get healthy?”

The first thing a good workers’ compensation attorney would do is pick up the phone and call the insurance adjuster. Many of the possible reasons for this happening can be solved in a five minute phone call by an attorney who knows what they are doing.

If that doesn’t work or as sometimes happens, no adjuster will actually answer the phone, a good attorney would force their hand by filing a petition for immediate hearing. That can get your case in front of an Arbitrator relatively quickly and would force the insurance company to either do the right thing or disclose how they made a decision that defies accepted medical practices.

In other words, this is annoying and frustrating, but we are goal focused people and there is a solution. So it’s important to find out why benefits get cut off in work comp cases, but even more important to figure out how to fix it.