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Does Workers’ Compensation Cover Surgery?

 

Workplace injuries happen to people across the nation every day. When they do, the injured employees are entitled to file Workers’ Compensation claims through their employers. Workers’ Compensation serves as a type of insurance that reimburses employees who have been hurt on the job for a portion of their lost wages, their out-of-pocket medical treatment, and some other related costs.

What happens if your injuries are serious enough to require surgery like orthopedic surgery, cosmetic surgery, or neurological surgery? In a perfect world, Workers’ Compensation would pay for your surgical procedures as well as any follow-up appointments, prescriptions, and therapy you would need afterward. The problem is that sometimes Workers’ Compensation insurance providers may deny payment for surgeries for a variety of reasons.

If this occurs, you should contact a Workers’ Compensation lawyer who practices in your state right away. The longer you wait after receiving a denial, the harder it can be for you from a health and stress perspective.

Why Would Workers’ Compensation Deny Covering a Surgery?

The first reason surgery may be denied is that the company that insures your workplace believes more conservative treatments have not yet been tried. Conservative treatments tend to cost less. However, your doctor or specialist may feel that surgery is warranted.

In that situation, your employer’s Workers’ Compensation insurance provider may disagree until you can prove that the surgery will be more beneficial than other measures. For instance, you may be asked to get a second opinion to substantiate that you need surgery rather than a different, less expensive, and less invasive treatment.

A second reason that Workers’ Compensation insurance providers deny surgery requests is that they believe the surgery is for another condition or injury sustained outside of the workplace. For example, the Workers’ Compensation company might argue that your surgery has nothing to do with your on-the-job accident or injury.

Another reason for surgery denials is the cost itself. A Workers’ Compensation representative may say that you can get surgery for a lower cost at another facility because the price given is unreasonable. If you go to a treating doctor who is not recognized as a qualified medical professional who is not authorized to practice, the surgery will almost certainly be denied.

What to Do After Getting Denied for Surgery by Workers’ Compensation?

It can be confusing and even angering to be told that you cannot get a surgery that may be is essential to your recovery. Knowing what steps to follow makes this moment a little easier.

First, find out why your surgery has been denied. Occasionally, denials happen because the insurance company has too little information from your treating physician. In that case, you may be able to get the insurance to reverse its denial decision by working with your physician to send the insurer the right paperwork.

What if the Workers’ Compensation representative explains that the insurance company wants you to get a second opinion or get an independent medical evaluation (IME) with a specific physician? If you refuse, you may have to avoid getting surgery or pay for it yourself. A better option is to consider the request. Getting a second opinion gives you the chance to provide supportive and objective documentation on your behalf. Additionally, it can be valuable if you originally went to a physician that was not authorized or recognized by the Workers’ Compensation provider.

Second, call a Workers’ Compensation lawyer. Speaking with someone who has knowledge of Workers’ Compensation regulations and recent court cases will be helpful. This is particularly important if there is any controversy about whether or not the surgery relates to your workplace injury. A lawyer can advise you on how to proceed based on your unique circumstances, which may include filing another Workers’ Comp claim or beginning litigation proceedings against the insurance company.

Third, keep attending all your appointments and taking all your prescriptions. Though you may not be able to get your surgery yet, you should still be your best possible advocate. Stopping your medications or canceling medical visits could make your experience worse by slowing or stopping the healing process.

Your employer’s Workers’ Compensation insurance is supposed to work for your interests and not against them. Therefore, if you receive a denial for surgical treatment, you should feel free to take action.

Piscataway Workers’ Compensation Lawyers at the Law Offices of Harold J. Gerr Help Injured Employees Get the Surgeries They Need

If you are denied necessary surgery, call the Law Offices of Harold J. Gerr and ask to speak with one of our Piscataway Workers’ Compensation lawyers. You can contact our team in Highland Park, New Jersey, at 732-537-8570, 877-249-4600, or fill out our online form to schedule a free consultation. We serve clients in like Metuchen, East Brunswick, South Plainfield, Bound Brook, Iselin, Piscataway, Perth Amboy, Middlesex, Sayreville, New Brunswick, South River, Colonia, Fords, Somerset, Old Bridge, and Edison.

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