Jun 2023

What To Do When Workers’ Comp Denies Surgery

Paperwork of a denied compensation claim.

A lawyer can help you secure the treatment you need.

While some work injuries can be resolved with rest, ice, and over-the-counter pain medication, others may require more extensive medical intervention, including surgery.

Fortunately, workers’ compensation is designed to cover the costs of reasonable and necessary surgeries to treat work-related injuries. However, the not-so-great news is that obtaining approval from the workers’ compensation insurance company can be a challenging process to navigate on your own.

If your request for surgery to address a work injury has been denied, a workers’ compensation attorney can provide the support you need to fight back and protect your rights.

What types of surgery are covered under workers’ comp?

In Massachusetts and Rhode Island, workers’ compensation generally covers all reasonable and necessary surgeries for work-related injuries.

The following types of surgery are commonly covered:

  • Surgery to repair fractures or broken bones.
  • Skin grafts for burns sustained at work.
  • Spinal fusion procedures.
  • Carpal tunnel release surgery.
  • Knee or shoulder surgeries.
  • Eye surgeries.
  • Neck or back surgeries.
  • Brain surgeries.
  • Reconstructive surgeries.
  • Any other surgeries deemed reasonable and necessary for treating work-related injuries.

If surgery is covered by workers’ compensation, the insurance company is typically responsible for paying the entire cost, including pre-and post-operative care, anesthesia, medications, and medical devices. There should be no co-pays, deductibles, or out-of-pocket expenses for the injured worker.

Additionally, workers’ compensation should provide a percentage of lost income while the worker is recovering from the surgery or if they are assigned to a reduced-paying “light duty” role due to the procedure.

Common reasons why workers’ comp denies surgery

Unfortunately, even when your doctor deems surgery necessary for your work injury, the insurance company may deny approval, leading to a frustrating and challenging situation. They might dispute the surgery’s “reasonableness and necessity” and suggest alternative treatments. In some cases, they may insist on a second opinion from a doctor more aligned with their perspective. Alternatively, they may argue that the injury requiring surgery is unrelated to work, thus not covered by workers’ compensation.

It’s important to recognize that insurance companies have a financial motive to act in this manner. Surgery can be costly, and their primary objective is to protect their own financial interests. In such circumstances, it becomes crucial to seek the assistance of a workers’ compensation attorney who can navigate the complexities of the system and advocate on your behalf.

Remember, your well-being and recovery should be the top priority, and legal representation can help you pursue the treatment you need.

How a workers’ compensation attorney can help

At The Law Offices of Deborah G. Kohl, we understand that getting the medical treatment you deserve shouldn’t be a frustrating experience. That’s why we advocate for the rights of injured workers in Rhode Island and Massachusetts. We help our clients fully understand their rights and options so they can make informed decisions that protect their best interests.

If your surgery has been denied by workers’ comp, we can thoroughly review your case, gather evidence, and build a strong argument to challenge the denial. Through negotiations with the insurance company, we can advocate for the approval of the surgery, guide you in filing an appeal, represent you in hearings, and present compelling evidence to obtain the outcome your case deserves.

Don’t let a denied surgery claim from workers’ comp prevent you from receiving the medical treatment your doctor recommends. Take action today. Contact us now to schedule your free consultation.

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