What is a common cause for disputes during claims resolution?

Disagreements over medical necessity are a common source of disputes during claims resolution in workers' compensation cases. In these scenarios, the injured worker and the insurer may have differing opinions about whether the medical treatment being claimed is appropriate and necessary for the compensable injury. Medical necessity is a crucial factor because workers' compensation covers treatments that are deemed essential for recovery related to job-related injuries.

When an adjuster evaluates the claim, they must assess the medical evidence provided and determine if the treatments align with established guidelines. If the insurance carrier believes that a certain medical procedure or therapy is not justified, this can lead to disputes, as the injured worker may feel entitled to those treatments. The complexity of medical diagnoses, treatment regimens, and the various opinions among healthcare providers can further complicate these disputes.

In contrast, while disagreements over work hours, underreporting of injuries, and company policies can contribute to tensions in a workers' compensation claim process, they are not as consistently central to the resolution of disputes as issues surrounding medical necessity. Thus, the focus on medical necessity captures a fundamental aspect of the claims assessment process, making it a common and significant cause of disputes.