According to law, employers must provide workers’ compensation benefits to their employees. Work comp benefits will pay if you injure yourself at work or develop a medical condition due to the nature of your job. The benefits cover your associated medical expenses and give you cash as compensation to cover lost wages.
The workers’ compensation system follows a no-fault rule. This means you do not need to prove your injury results from the employer’s negligence or wrongdoing. However, the insurance provider may deny your claim or a specific request, including surgery.
If worker’s comp denied your surgery claim and you’re wondering what to do, this post is for you.
Who Can Deny Your Surgery?
Your insurance provider is the decision-maker for your surgery claim. However, your insurer might deny a surgery claim after consulting with a workers’ comp doctor or other medical healthcare professionals. The process that leads to denial is as follows:
Your treating doctor recommends a surgery
The insurer receives your doctor’s recommendation, but the claim adjuster does not agree with the recommendation.
In this case, your insurer brings in a third-party doctor for a second opinion. In many cases, the second opinion declares that you do not need a surgery recommended by your doctor.
This gives your insurance provider the grounds to deny your surgery request.
Can Workers’ Comp Deny Surgery?
Yes, if the workers’ comp insurance provider believes that your surgery is not necessary or not reasonable. If the workers’ comp thinks that your injury did not occur at work or due to your job duties, they may deny your surgery request.
Reasons for Denial to Surgery Request
There are several reasons the insurance company denies your claims. Here are four primary reasons that allow an insurance company to deny surgery.
Disbelief in Your Claim
There’s a chance that your employer or insurance provider doesn’t believe that you were injured to the extent that you need surgery. Unfortunately, many work injuries, such as muscular strains and back injuries, do not appear on an x-ray or MRI. In these scenarios, your insurer may be skeptical about a surgery recommendation from your doctor.
Sometimes, you might have to put up with an injury or condition until it is severe enough to appear in an x-ray, MRI, or any other medical report. Only then will the insurance provider approve the surgery.
You were Intoxicated
If your injury requires surgery and the incident occurred when you were under the influence of alcohol or drugs, your employer or insurance company can deny the surgery claim. In some cases, the employer may ask you to take an alcohol or drug test after your accident at the workplace. However, you should get tested right away.
If the employer didn’t ask for a drug or alcohol test, the insurer might deny a claim based on invalid information or inaccuracy. The employer may bring witnesses stating that you were intoxicated at the time of the accident and the injury resulted from your own negligent behavior.
Dispute from Your Employer
Sometimes, your employer can also dispute your workers’ compensation claim. One of the common reasons for this dispute is when the employer does not believe or think that your injury requires surgery or that you did not sustain an injury at work.
The employer might suspect that you suffered from an injury at the workplace, not while performing your duties. This can result in the employer denying your claim processing or informing the insurance provider about the suspicion, which may lead to the insurance company denying surgery.
In this case, the employer or workers’ comp may not consider your doctor’s recommendation and seek a second opinion from a third-party doctor or medical expert. The second opinion will determine whether your claim to injury that needs surgery is a result of a workplace accident or you have a condition that requires surgery at all.
However, you must remember that if you suffer from a pre-existing injury or medical condition and need surgery because work conditions exacerbated your symptoms, you fall in the work-related injury category.
Missing Your Filing Deadline
In California, you must report a workplace injury within 30 days of the accident. So, if a doctor recommended surgery and you failed to file a claim within 30 days, the insurance company will deny your surgery claim.
How to Settle a Denied Workers Comp Claim?
Suppose your workers’ compensation insurer refuses to accept or pay for your surgery. In that case, you might feel tempted to contact your personal health insurance company and ask them to cover the cost. However, your personal insurance company will not pay for a surgery associated with a workplace injury.
This can be a very tricky situation, and you must not just accept the denial from your workers’ comp, especially if your doctor recommends an immediate surgical procedure. Most insurance providers will expect or discourage you from giving up pursuing your surgery claim after denial.
However, if you believe your request is genuine, you must not stop and fight for your right to benefits. Upon denial of surgery recommendation by workers’ comp, you must contact an attorney specializing in workers’ compensation laws. The attorney will not only explain the entire process but also help you gather the right document and coordinate with your doctor.
In case your workers’ comp requests a second opinion that denies your surgery, your attorney will look into the second opinion report to ensure that insurer is not trying to avoid paying for surgery deliberately.
Seek Legal Assistance for Workers’ Comp Denying Surgery
If you live and work in California and face a denial of surgery claim for any reason, you must not give up. Latimer Law is a law firm with years of experience dealing with surgery denial by workers’ comp. Our expert lawyer will work with you to collect all the evidence and medical report to support your surgery claim.
Furthermore, we will investigate the authenticity of the denial and negotiate with the insurance company to cover your surgery. You can contact us for a free consultation about the value of your compensation claim. Simply call us on 510-444-6555.