If your doctor recommends surgery after a workplace injury, your employer’s workers’ compensation insurer should pay for it. However, the insurance company may deny payment for various reasons, and they are not always fair. Fortunately, a denied claim or rejected treatment isn’t necessarily the end. You have options and should consult an experienced workers’ compensation lawyer for help.
Who Has the Authority to Deny My Surgery for a Work-Related Injury?
The insurance adjuster can decide whether to approve or deny your surgery. They represent the insurance carrier and oversee workers’ compensation claims.
Why Do Worker’s Compensation Insurance Companies Deny Treatment?
Like any business, insurance companies want to maximize income and minimize expenditures. Surgery is expensive. So, the insurer will likely seek reasons to reject the doctor’s recommendation.
Although an injured worker can appeal a claim denial, the red tape is enough to make many employees with valid claims give up in frustration. When that happens, the insurance company wins, keeping the money the injured worker is entitled to under Georgia law. Don’t give up — talk to a lawyer instead.
Possible Reasons for Denials
The insurer might deny a surgery request for various reasons. The company may argue:
- Surgery doesn’t offer any medical benefits, such as curing the disease, alleviating pain, or restoring loss of mobility.
- The patient has reached maximum medical improvement (MMI), meaning surgery will not improve the condition.
- The injury isn’t work-related, so workers’ compensation shouldn’t pay for the procedure.
- The doctor isn’t on the employer’s panel of approved physicians.
- The injured worker didn’t follow their doctor’s treatment plan, causing the injury to worsen.
- The insurer disagrees with the physician’s diagnosis or believes the injury doesn’t require surgery.
- The employee didn’t report the job-related accident or file their claim by the deadline.
- The insurer may claim the need for surgery is due to a pre-existing condition such as degenerative disc disease.
How Can I Get My Surgery Approved
You might be able to resolve the problem and get the workers’ comp adjuster to approve your surgery by:
- Talking to the adjuster – Contact the insurer to explain why surgery is necessary. The denial might be a miscommunication. Maybe your claim form includes incomplete or inaccurate information. Submitting relevant evidence to prove you need surgery might convince the insurer to approve it.
- Ask for a hearing – You can request a hearing with the Georgia State Board of Workers’ Compensation (SBWC). At the hearing, you must demonstrate why the insurer should approve your surgery and pay the expense.
- File an appeal – During an appeal, the workers’ compensation board reviews the initial decision and decides whether to approve or deny it.
Your claim’s success depends on providing strong supporting evidence during the hearing and appellate phases of your case. A knowledgeable workers’ compensation attorney can determine what you need to give you the best possible chance of success.
Talk to a Workers’ Comp Lawyer if Your Surgery Has Been Denied
The Law Offices of William F. Underwood, III, P.C. puts people first. If you need surgery and receive a denial from the insurance company, our workers’ compensation attorneys will fight fiercely for you to get the medical care you deserve. Call or contact us today for a free consultation with a workers’ comp lawyer in Georgia.
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