Does Workers’ Compensation Pay for Surgery?
When you’re injured on the job, it can be a stressful and confusing time, especially if your injuries require surgery and an extended time away from work. You likely have many questions about how you will pay for your medical expenses and if workers’ compensation will pay for your surgery.
In Pennsylvania, if you are injured on the job, you are entitled to coverage for your medical bills through your employer’s workers’ compensation insurance provider. This is true for everything from ambulance services and diagnostic tests to surgery and therapy.
Unfortunately, some employers make it difficult for injured employees to obtain and pay for this kind of treatment, even when it is warranted and ordered by a doctor.
We’re here to help you understand your rights and navigate the complexities of workers’ comp. Let’s take a look at the process for a surgery request through workers’ compensation and what to do if your surgery is denied by the insurance company.
How to Get Your Surgery Covered by Workers’ Comp
Workers’ compensation benefits pay for medical treatments that are reasonable and necessary after an injury, including surgery. Unfortunately, insurance companies are notorious for denying benefits and may deny your request. To have the best chance of having your surgery request approved the first time, it’s important to follow the workers’ compensation claims process from the very beginning.
In Pennsylvania, the process for a surgery request through workers’ compensation involves several steps, beginning with the immediate steps after your injury. Typically, the steps include:
- Report the injury: The first step is to report your work-related injury to your employer as soon as possible. In Pennsylvania, you have 120 days from the date of the injury to notify your employer. As a general rule, you should report your injury as soon as possible, though, preferably within 21 days to receive full benefits.
- Seek medical treatment from an approved physician: Your employer may provide a list of designated healthcare providers that you must choose from for the initial 90 days of treatment. After the 90-day period, you can choose your own healthcare provider.
- Medical evaluation and recommendation: Your treating physician will evaluate your condition and determine if surgery is medically necessary to treat your work-related injury. If surgery is recommended, your doctor will need to provide documentation and justification for the surgery to your employer’s workers’ compensation insurer.
- Preauthorization: Although Pennsylvania does not have a specific preauthorization requirement for medical treatment under workers’ compensation, insurance companies may still request additional information or documentation before approving the surgery. It is essential to work closely with your treating physician to ensure all necessary documentation is submitted.
- Surgery approval or denial: Your employer’s workers’ compensation insurer will review the submitted documentation and determine if the surgery should be covered under your workers’ compensation claim. If approved, the surgery will be covered by the workers’ compensation insurance.
If your employer’s insurer is disputing your need for additional medical treatment, including surgical intervention, contact an experienced workers’ comp attorney to help you fight for your rights.
What to Do If Your Surgery is Denied by Workers’ Comp
When you’re injured at work and require surgery, the last thing you want to face is a denial from your employer’s workers’ compensation insurance. Unfortunately, this can happen for various reasons, leaving you with mounting medical bills and uncertainty about your future.
If your surgery is denied, you are not without options. Here are some recommended steps to take to get the procedure covered by workers’ comp:
Step 1: Consult with an Experienced Workers’ Compensation Attorney
Navigating the complex world of workers’ compensation can be challenging, especially when dealing with surgery denials. An experienced workers’ compensation attorney can help you understand your rights, review your case, and provide guidance on the best course of action. They can also assist in gathering additional evidence and negotiating with the insurance company on your behalf.
Step 2: Understand the Reason for Denial
The next step when facing a surgery denial by workers’ comp is to understand the reason behind it. Insurance companies may deny your claim due to insufficient documentation, lack of medical necessity, or disputes about whether the injury is work-related. Review the denial letter carefully and identify the specific reasons provided by the insurer. Your attorney can also review the denial letter to help formulate a path forward to get your surgery covered by the insurance company.
Step 3: Gather Supporting Documentation
Once you understand the reason for the denial, gather all relevant documents that can support your case. This may include medical records, doctor’s recommendations for surgery, diagnostic test results, and any other evidence demonstrating the necessity of the surgery for your work-related injury. It’s also essential to keep records of all communication with your employer and the insurance company. Your attorney can help you gather the proper documentation.
Step 4: Pursue Your Options
If your surgery is denied by workers’ comp, you have a number of options to pursue. In Pennsylvania, you can file a Petition before a workers’ compensation judge. Your attorney can guide you through the process, ensuring that all necessary paperwork is completed, and deadlines are met. At the hearings, your attorney will present your case and evidence supporting the need for surgery.
There are also things that can be done short of initiating litigation. The best workers’ compensation lawyers make sure that their clients’ claims are well postured, in order to minimize the risk of surgery being denied by the insurance company and, if it is, to be in the strongest position to successfully argue and overturn this determination.
Step 5: Prepare for an Independent Medical Examination (IME)
As part of the decision process, you may be required to undergo an Independent Medical Examination (IME) by a doctor chosen by the insurance company. The purpose of the IME is to provide an unbiased evaluation of your medical condition and determine if the surgery is necessary. However, the reality of the workers’ compensation system is that the doctors who perform these “independent” evaluations are chosen by the insurance companies for certain reasons. Thus, it can be extremely beneficial consult with a top workers’ comp lawyer who can provide guidance on how to approach the IME, fill you in on what to expect and take immediate measures to fight an adverse opinion by the insurance carrier’s doctor.
Facing a surgery denial by workers’ comp can be a stressful and frustrating experience. However, by understanding the reasons for denial, gathering supporting evidence, and working with an experienced workers’ compensation attorney, you can increase your chances of having payment for your surgery denied and ensure that you receive the medical care you need for your work-related injury.
If you’re struggling with a surgery denial in Pennsylvania, don’t hesitate to reach out to our team of workers’ comp attorneys for assistance and support.
Your Workers’ Comp Law Firm in Lancaster, PA
At Georgelis, Larsen & Sabatino Injury Law Firm, P.C., our sole focus is on workers’ compensation and personal injury cases. Our extensive experience in representing injured workers has provided us with a comprehensive understanding of the process, how to safeguard employees’ rights, and how to handle appeals for denied claims.
If you have been hurt on the job and your doctor recommends surgery as part of your recovery, the last thing you should be worrying about is how to pay for your medical bills. Workers’ compensation benefits are designed to help you with that burden. If the insurance company had denied your surgery, we can help you fight for your rights.
Your employer has a team of attorneys striving to reduce their financial responsibilities following a workplace injury, and it’s only fair that you have equal representation. Our dedicated, assertive, and seasoned workers’ comp lawyers are prepared to stand up for your rights within the legal system.
Your primary concern should be recovery, not dealing with paperwork and legal matters. Get in touch with us today at 1-800-HURT-NOW for a free consultation or connect with us online. We’ll assess your case at no cost, and we won’t charge a fee unless we win your case.
