When Workers Compensation Refuses to Pay for Surgery

Workers’ compensation covers all the medical treatment costs for the injuries sustained at the workplace.

The employer or the insurance company designates a doctor, who provides medical treatment for the injuries. However, if the injured worker is not satisfied with the treatment, they can bear the expenses and seek a second opinion. The second doctor or the original doctor may recommend surgery as the best possible treatment for the injury. The problem arises when the insurance company refuses to pay for the surgery. Our St. Louis work comp attorney regularly comes across such cases, where the physician has recommended surgery, but the workers’ compensation refuses to pay for it. If you are tangled in a similar web, the following answers should help you.

How Can Workers Compensation Refuse to Pay for a Surgery?

To get the insurance company to pay for the surgery, the injured worker should be able to prove that the surgery is reasonable, necessary, and related to the work injury. The insurance company decides whether the surgery is reasonable, necessary, and related to work injury by way of an independent medical exam. On the basis of this report, the insurance company decides whether or not to approve the cost. If the IME doctor feels that surgery is not necessary, your claim will be denied.

What Should an Injured Worker Do Once the Insurance Company Has Denied Payment?

First, it is important to understand why the dispute occurred, and based on this, you can make an appeal. The insurance company can reject the claim stating that the physician has still not tried other available treatment alternatives. Another reason could be that the insurance company feels that the injury is a mere exaggeration of a pre-existing condition and that the surgery is not related to the work injury. 

To settle the dispute the injured worker will need to plead their case before a workers compensation judge. Once the insurance company has denied payment for the surgery, the injured worker can request a hearing on the matter. The judge reviews all medical records and testimonies and then makes a decision. However, either of the parties can make an appeal against the decision. It is not necessary to hire a St. Louis work comp attorney to plead your case, but it is always a good idea to have a legal expert represent your case.

If the insurance company has refused to pay for the surgery or is causing unnecessary delays, consult The Law Office of James M. Hoffmann at (314) 361-4300. We will answer your questions and can help you receive the rightful compensation that you deserve.

Influencing Factors & Denied Claims

Photo credit: Ted Eytan via Flickr