Can the Workers’ Compensation Insurer Deny Surgery My Doctor Ordered?

If you've been told by your workers’ compensation doctor that surgery is required for your injury, it may be a shock to have the surgery denied. Unfortunately, there are several reasons why this can happen.

Reasons for a Claim Denial

Slip and fall accidents, heavy lifting accidents, work truck accidents, and injuries caused by defective machinery or equipment can result in serious injuries that require surgery to repair. However, for specific treatment to be approved for workers’ compensation benefits, your claim must meet the following three criteria:

  • Causation: Your need for medical treatment must be the direct result of a workplace accident. If you can't establish that the injury was caused by something that occurred while on the job, the claim can be denied.
  • Likelihood of effectiveness: Treatment will only be approved if it's reasonably likely to cure your condition and/or allow you to return to suitable employment.
  • Authorized provider: Workers’ compensation laws require treatment to be administered by an authorized provider on your employer's panel of physicians. A surgery performed by someone who doesn't have the necessary approval could legally be denied.

If there's a problem in any one of these areas, your claim may be denied, regardless of what your doctor previously said about the recommended treatment.

Independent Medical Examinations (IME)

When an insurance company requests that you see another doctor after your doctor already recommended surgery, it is typically an indication that the company may be looking to deny authorization for the surgery. The insurer is likely sending you for an independent medical examination seeking to obtain an opinion that the surgery recommended by your doctor is not necessary.  That opinion may then be used as a basis for denying your claim pending a hearing before an administrative law judge.

The phrase "independent medical exam" (IME) is a bit misleading, since the doctors who conduct these examinations regularly receive referrals from workers’ compensation insurance companies. This may give them financial incentive to write a report favoring the insurer's financial interest, regardless of what the exam reveals. 

Don't agree to submit to an independent medical exam before discussing the issue with your attorney. After evaluating your case, your attorney can develop a strategy to help counter any negative reports from the independent medical examiner.

Using Your Own Health Insurance to Pay for Surgery

In some circumstances, using your health insurance to pay for surgery may be a better option than waiting for a hearing to have a judge determine whether you are entitled to have surgery under your workers' compensation claim. Doing it this way will allow you to have the surgery sooner, and may provide additional leverage on your claim. Your attorney may then be able to settle your case prior to a hearing, and get the cost of the surgery taken into account in the settlement amount.

However, using your health insurance benefits can complicate your case. Before taking action, it is important to discuss this issue at length with your attorney before making a final decision.

Protecting Your Right to Compensation

The legal team at Rechtman & Spevak has extensive experience helping injured Georgia workers maximize the settlement value on their claims. If your employer or insurer is attempting to: deny your workers’ compensation benefits; suggest your injuries aren’t severe enough to require a recommended surgery; or terminate your employment altogether, we can help. Please contact us for a free, no-obligation case review.