Does Workers’ Comp Pay for Surgery?

If You Have Suffered a Workplace Accident or Illness, Workers’ Compensation Should Pay For Medical Benefits, Including Surgery. Let Our Philadelphia, PA Workers’ Compensation Attorneys Help You Get the Benefits You Deserve

Workers’ compensation is a critical resource for workers who get injured on the job, offering no-fault insurance benefits through their employer for medical expenses, lost wages, and even disability when someone has suffered a work-related injury or illness. It will pay for medical expenses as they relate to a work injury, including doctors’ visits, medications, hospitalizations, diagnostic tests, medical equipment, and surgeries.

A Workers’ Compensation Insurance Company Can Deny Your Surgery

However, there are cases when the workers’ compensation insurance company may deny a surgery. Because surgery will require added medical benefits, extra time away from work, and potential disability benefits coverage while you heal, workers’ compensation will only pay for surgeries that are considered “necessary and reasonable.”

Under Pennsylvania’s workers’ compensation laws, if your physician determines that you require surgery, it should be covered by your workers’ compensation insurance. Unfortunately, workers’ comp is administered through independent insurance companies that regularly deny claims if they feel they are not reasonable and necessary. How do they justify this? This is when you may need the assistance of a skilled Philadelphia, PA, workers’ compensation lawyer.

The General Procedure for a Surgery Request Through Workers’ Comp

After a work-related injury, you will typically be directed to an employer-approved doctor who will diagnose and provide treatment for you for the first 90 days. You may then see a doctor of your choice. However, if the doctor of your choice suggests that surgery is your best option, unless it is approved by your workers’ compensation insurance company, you may not be covered. This is important information to have before you agree to any surgery.

In most cases, except in an emergency, a doctor will want to know that you are covered by insurance before performing any surgery. The doctor will send their recommendation to the insurance company, which the insurance company’s adjuster then reviews.

At this point, the adjuster may not agree that the surgery is necessary, and an independent medical exam may be ordered. If the IME physician doesn’t agree with your doctor’s assessment and believes that your surgery is not necessary or reasonable, your claim can be denied by the workers’ compensation insurance company.

What Should You Do If Your Surgery Has Been Denied by the Worker’ Comp Insurance Company?

There are several reasons that a workers’ comp insurance company may deny your request for surgery. They may have felt that your doctor still hadn’t explored other available treatment options before surgery. They may even feel that the injury was a pre-existing condition and not work-related at all.

But insurance companies that handle workers’ compensation must operate under state laws governing the program. If your doctor feels the surgery is in your best interest and you have been denied by the insurance company, you can make an appeal and have your case heard before the Workers’ Compensation Appeal Board. If your appeal is denied, you may then take your case to the Pennsylvania Commonwealth Court.

Getting the Assistance of an Experienced Philadelphia, PA Workers’ Compensation Attorney to Navigate a Workers’ Compensation Appeal for Surgery Denial

Navigating an appeal for workers’ compensation can be a complex endeavor, requiring that you go through the necessary steps one after the other. One mistake or misstep can work against you. Having the representation of an experienced Philadelphia, PA, workers’ compensation lawyer in your corner ensures that you understand the process and each step is completed properly and within necessary time constraints.

At HGSK, we have represented individuals who have suffered workplace injuries and illnesses for decades. If you have questions about a workplace accident or workers’ compensation claim, we can help you get the benefits you deserve. Call us at (267) 350-6600 or contact us through our online contact form to schedule a free consultation.