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What to Do if Workers' Comp Denies Surgery

Close-up of two surgeons' gloved hands and instruments as they perform surgery on a patient.

The right attorney can help you get the treatment you need for a work injury.

Some work injuries heal with rest, ice, and over-the-counter pain medication. Others require more extensive treatment. Unfortunately, many on-the-job injuries need surgery to fully heal.

The good news is that if you were hurt at work, workers' compensation should pay for reasonable and necessary surgery to treat the injury. The less-good news is that the workers' compensation insurance company has to approve it, and that's sometimes a difficult process. If your surgery for a work injury has been denied, a workers' compensation attorney can help you fight back.

What types of surgery are covered by workers' compensation in Pennsylvania?

Workers' compensation covers all reasonable and necessary medical treatment for a work injury, including surgery. In principle, any type of surgery can be covered by workers' comp if it is reasonable and necessary to treat a work injury or illness. Workers' comp may cover:

  • Surgery to repair broken bones (fractures)
  • Skin grafts for work-related burns
  • Spinal fusion
  • Carpal tunnel surgery
  • Knee surgery
  • Shoulder surgery
  • Eye surgery
  • Neck surgery
  • Brain surgery
  • Reconstructive surgery
  • All other types of surgery

If a surgery is covered by workers' comp, then the workers' compensation insurance company should pay for the full cost of surgery and related expenses, including pre- and post-operative care, anesthesia, medications, medical devices, and so on. There are no co-pays, deductibles, or other out-of-pocket expenses.

Workers' comp should also cover a percentage of your lost income while you are out of work recovering from the surgical procedure, or if you need to take on a "light duty" role with reduced pay due to the procedure.

How and why the insurance company may deny surgery

Unfortunately, even if your doctor recommends surgery for your work injury, the insurance company may refuse to approve it. They may dispute whether the surgery is "reasonable and necessary" and try to steer you toward other types of treatment. They may also require you to get a second opinion — often with a doctor who is more sympathetic to their point of view. Or they may claim that the injury that requires surgery is not work-related and thus not covered by workers' comp.

Insurance companies have a financial incentive to do this. Surgery is expensive, and their job is to protect their bottom line. But if you're in this situation, it can be extremely frustrating. You just want the treatment your doctor recommended so that you can heal and get back to your job — and your life.

How a workers' compensation lawyer can help

If surgery for your work injury has been denied, there are several steps a workers' compensation attorney can take on your behalf to correct the situation, including:

  1. We can negotiate with the workers' comp insurance adjuster or case manager to get approval for your surgery. Sometimes, all it takes is a call or letter from your attorney to get the insurance company to understand why the surgery is reasonable and necessary.
  2. If that doesn't work, we can file a claim petition with the Pennsylvania Bureau of Workers' Compensation (BWC) to challenge the denial and compel the insurance carrier to pay for the surgery. We can represent you in a hearing before a workers' compensation judge (WCJ) to demonstrate that the surgery is reasonable and necessary treatment for your work injury.
  3. If the judge sides with the insurance company, we can appeal the decision to the Workers' Compensation Appeal Board (WCAB). The Appeal Board's decision in turn can be appealed to the Commonwealth Court of Pennsylvania, and from there to the Supreme Court of Pennsylvania.

In short, if your doctor is recommending surgery but the insurance company is refusing to pay for it, you need to talk to a workers' compensation lawyer right away to protect your legal rights and options. You've already been hurt at work; don't get hurt twice by the insurance company. Contact Vellner Law, P.C. today to find out how we can help.

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