When you suffer an injury while on the job, workers' compensation insurance is supposed to cover your medical expenses—including necessary surgeries. However, it's not uncommon for workers' compensation insurance companies to deny coverage for certain surgeries. This can be both frustrating and overwhelming, leaving you wondering why your claim was denied.
What Are My Options After a Workers' Compensation Surgery Denial?
When your workers' comp surgery gets denied, there are steps that our Georgia workers' compensation lawyers can take to help you get the medical care you deserve. We can:
Call the Insurance Adjuster
Sometimes, a quick phone call can solve the problem, such as if there is a mistake or misplaced paperwork. It's not common, but it can happen. Even if the adjuster doesn't provide a solution, calling them is the quickest way to uncover the reason behind the denial.
Request Medical Treatment Authorization
According to Board Rule 205(c), if the insurer is delaying or refusing to authorize specific medical treatment ordered by your authorized treating physician, you can file a Petition for Medical Treatment (WC-PMT) with the State Board of Workers' Compensation requesting that an Administrative Law Judge order the insurance company to authorize the recommended treatment. The judge will listen to the parties' contentions during a telephonic conference, and then can order the insurance company to approve the treatment. The insurer can avoid the telephonic conference either by authorizing the requested treatment prior to the call or by filing a formal denial of the treatment on a Form WC-3.
Request a Hearing
If the WC-PMT process does not result in the recommended treatment being authorized, you can file a Form WC-14 to request an evidentiary hearing before an Administrative Law Judge. After you submit this form to the State Board of Workers' Compensation, you will receive a notice telling you when and where the hearing will occur. Since this is a legal matter, hiring a skilled workers' compensation attorney to present your case is a good idea.
File an Appeal
If you disagree with the judge's decision, you can appeal it. The Appellate Division of the Georgia State Board of Workers' Compensation handles workers' compensation appeals. They will review your case and make a final decision.
Denied Surgical Treatment Doesn't Necessarily Mean the End of the Road
The last thing you need while dealing with your injury is a surgery denial. It could mean delayed recovery and prolonged financial problems. However, it is important to remember that it is not necessarily the end of the road.