If your workers’ compensation insurer is refusing to approve surgery recommended by your doctor, you don’t have to face this alone.
Insurance companies often deny medical treatments, including surgeries, to save costs, but that doesn’t mean you’re out of options. You can take steps to appeal the decision and secure the care you need.
Start by understanding why the claim was denied and work with a skilled workers’ compensation attorney to challenge the decision and protect your rights.
Who Has the Authority to Deny My Surgery for a Work-Related Injury?
An insurance adjuster has the authority to approve or deny your surgery under workers’ compensation.
While they represent the insurance company’s interests, their decision isn’t final if your surgery is denied. You have the right to challenge their decision by providing additional medical evidence, seeking a second opinion, or appealing the denial with the help of a workers’ compensation attorney.
Understanding the process can help you get the care you need.
Why Do Worker’s Compensation Insurance Companies Deny Treatment?
Workers’ compensation insurers often deny surgery claims to reduce costs, even when the procedure is medically necessary.
Surgery is costly, so the insurer may look for reasons to reject your doctor’s recommendation, such as questioning the necessity of the surgery or disputing the injury’s connection to your job.
While claim denials can be frustrating and time-consuming, they are not the final word. Many injured workers successfully appeal these decisions and secure the care they need.
Don’t let the insurer’s tactics discourage you—consulting an experienced workers’ compensation lawyer can help you navigate the appeals process and fight for your rightful benefits.
Why Is Workers’ Comp Denying My Surgery? Common Reasons Explained
The insurer might deny a surgery request for various reasons. The company may argue:
- Surgery doesn’t offer any medical benefits, such as curing the disease, alleviating pain, or restoring loss of mobility.
- The patient has reached maximum medical improvement (MMI), meaning surgery will not improve the condition.
- The injury isn’t work-related, so workers’ compensation shouldn’t pay for the procedure.
- The doctor isn’t on the employer’s panel of approved physicians.
- The injured worker didn’t follow their doctor’s treatment plan, causing the injury to worsen.
- The insurer disagrees with the physician’s diagnosis or believes the injury doesn’t require surgery.
- The employee didn’t report the job-related accident or file their claim by the deadline.
- The insurer may claim the need for surgery is due to a pre-existing condition such as degenerative disc disease.
How Can I Get My Surgery Approved?
You might be able to resolve the problem and get the workers’ comp adjuster to approve your surgery by:
Talking to the Adjuster
Contact the insurer to explain why surgery is necessary.
The denial might be a miscommunication. Maybe your claim form includes incomplete or inaccurate information. Submitting relevant evidence to prove you need surgery might convince the insurer to approve it.
Ask for a Hearing
You can request a hearing with the Georgia State Board of Workers’ Compensation (SBWC). At the hearing, you must demonstrate why the insurer should approve your surgery and pay the expense.
File an Appeal
During an appeal, the workers’ compensation board reviews the initial decision and decides whether to approve or deny it.
Your claim’s success depends on providing strong supporting evidence during the hearing and appellate phases of your case. A knowledgeable workers’ compensation attorney can determine what you need to give you the best possible chance of success.
Frequently Asked Questions
Can Workers’ Comp Deny Surgery Recommended by My Authorized Treating Physician?
In Georgia, workers’ compensation will pay for all reasonable and necessary medical treatment after a workplace injury.
However, even if your doctor is an authorized treating physician, the insurance company may dispute whether a recommended procedure is medically necessary.
If the insurer denies coverage for a recommended surgery, you may need to undergo an independent medical exam (IME) by a doctor chosen by the insurance company. The IME provides a second opinion, which the insurance company will assess before deciding whether to approve the surgery.
If they still deny coverage, a workers’ compensation attorney can help challenge the decision and fight for the medical care you are entitled to.
How Long Does It Take to Get Surgery Approved After a Denial?
There is no guaranteed timeline for approval of surgery after a workers’ compensation denial.
The process can vary depending on several factors, including whether the insurer requests an independent medical exam (IME), how long it takes the physician to provide the results, and how long the insurer takes to review the information and make a decision.
If you need to appeal to the State Board of Workers’ Compensation (SBWC), the process may take additional time. Because timelines can be unpredictable, having a workers’ compensation attorney assist you can help keep your case moving as efficiently as possible.
What Evidence Helps Overturn a Surgery Denial?
You will need compelling medical evidence to appeal a denied surgery claim.
Examples of evidence that could overturn a denial may include records and progress notes from your authorized treating physician, diagnostic test results, MRI/CT scans, independent medical exam (IME) reports, expert opinions, and reports showing how your impairments limit your ability to do your job.
A workers’ comp lawyer can help gather the records to support your need for surgery.
Can I Choose My Own Surgeon Under the Georgia Workers’ Comp System?
Generally, no. In Georgia, your employer is required to provide a Panel of Physicians approved treat work-related injuries.
Workers are permitted one change of physician without permission from the employer or the State Board of Workers’ Compensation (SBWC). Any other changes require authorization.
What if the Insurer Claims My Condition is Pre-Existing?
Having a pre-existing condition does not automatically prevent you from obtaining workers’ compensation in Georgia.
However, to qualify for coverage, you must establish that your pre-existing condition was aggravated by performing work-related duties. Robust evidence is vital to support your claim, such as:
- Documents showing a change in your treatment needs due to the workplace injury
- Proof of increased impairment that affects your ability to work
- Medical records indicating when you began experiencing aggravated symptoms, notified your employer, and filed your workers’ comp claim
Because insurers scrutinize claims involving pre-existing conditions closely, it’s a good idea to have a workers’ compensation lawyer review your case and address insurance disputes.
Talk to a Workers’ Comp Lawyer if Your Surgery Has Been Denied
The Underwood Law LLC puts people first. If you need surgery and receive a denial from the insurance company, our workers’ compensation attorneys will fight fiercely for you to get the medical care you deserve.
Call or contact us today for a free consultation with a workers’ comp lawyer in Georgia.
Site by