What If Workers’ Compensation Won’t Pay for My Surgery?

This page has been updated on January 13, 2022.

You have been injured at work and need medical treatment. For many workers, getting workers’ compensation to cover their claims for medical benefits and lost wages can seem like an incredible battle. After successfully winning that fight, it may seem like smooth sailing with medical expenses covered and your injury on the mend.

Unfortunately, however, in some instances, even after your workers’ compensation is approved, you may still have to battle with an insurance company to get the treatment you deserve. Insurers do not always agree to provide employees with the medical procedures that they believe they need.

Why Are Surgeries Denied in Cherry Hill?

Once you have entered the workers’ compensation process and are having your medical bills covered by a workers’ compensation insurer, you must get approval for treatments from your doctor. This is because workers’ compensation is only obligated to cover your expenses arising from your workplace injury – not any and every medical condition for which you may wish to seek treatment.

When you request approval of a significant medical procedure, your workers’ compensation insurer will evaluate whether that medical procedure seems necessary. If they do not believe it is, they can deny coverage for that procedure.

For example, if you tear your ACL while on the job, you may need surgery to repair the ligament. But repairing the ligament typically doesn’t mean that a whole new knee is necessary. So, if you request authorization for a total knee replacement after your ACL injury, workers’ compensation may deny that request as unnecessary (unless there is a valid medical basis for the surgery).

The difficulty arises when workers’ compensation denies you coverage for a surgery or medical procedure that you and your doctor believe is necessary, but the insurer decides is not. This can happen when a procedure is new or experimental, or where there are a variety of methods for treating the injury that you have.

It is also more likely to arise when the medical procedure you are seeking approval for is expensive. This is simply because workers’ compensation insurers are more likely to scrutinize significant expenses. They stand to lose money by authorizing all of their patients to get expensive procedures.

Protecting Your Rights in the Workers’ Compensation System

If you need a hearing for your injury and your request for coverage is denied, there are several important steps that you can take to protect your health and your pocketbook.

First, if the surgery is medically necessary and cannot wait, and you have personal health insurance, use your health insurance provider to cover the surgery rather than a workers’ compensation insurer. You will likely be required to pay co-pays and other fees if you go this route, but it helps to protect your top priority – your health.

Even after using your health insurer, you can still pursue a claim to recover these costs through your workers’ compensation insurer. Using a health care insurer in the interim simply allows you to get the help that you need without waiting through the lengthy claims procedure.

Second, keep excellent documentation of your medical condition, your doctor’s recommendations, and the need for the surgery. Your workers’ compensation insurer may not have thoroughly reviewed these documents in considering your request and information contained in these records may help to prove that the surgery you are requesting is necessary.

Finally, you should reach out to an attorney to make a claim for coverage of your requested procedure and have a hearing on your claim. You will have the opportunity to present evidence on why the surgery is necessary and why workers’ compensation should be required to cover it.

If you are successful, not only will you be awarded the right to have the surgery and reimbursed for costs you have incurred so far in the process (such as medical bills if you paid for it yourself), but you will also be entitled to have your workers’ compensation insurer pay the attorneys’ fees that you incurred in bringing a claim.

New Jersey Attorneys Protecting Your Right to Medical Freedom

If you are trying to recover from a work-related injury and get back on your feet, the last thing you need is to have a necessary treatment denied by your workers’ compensation insurer. When that happens, the workers’ compensation attorneys at Petro Cohen, P.C. are available to assist you in getting the treatment you need and seeking compensation or coverage from the insurer.

Petro Cohen, P.C. has been consistently recognized as one of New Jersey’s leading firms in the area of workers’ compensation. Since 2010, the law firm has been named among Best Law Firms in America® in New Jersey for Workers’ Compensation. Frank Petro, a founding partner and head of the firm’s Workers’ Compensation Department, has received the highest rating (AV) from Martindale-Hubbell, the world’s foremost authority on law firm credentials. The AV rating is only for lawyers considered the top in their field. For 25 consecutive years, Mr. Petro has been named Best Lawyers in America® for Workers’ Compensation. Additionally, Mr. Petro has been named on the NJ Super Lawyers® list for 15 consecutive years in the practice area of workers’ compensation. He is also certified by the New Jersey Supreme Court as a Workers’ Compensation Law Attorney, the highest specialty certification available to workers’ compensation attorneys in New Jersey, and has held this certification since its inception in 1998.

The attorneys at Petro Cohen, P.C. take great pride in helping hardworking people just like you. The workers’ comp team of lawyers has over 100 years of combined experience, having successfully handled tens of thousands of litigated workers’ compensation cases throughout New Jersey. This experience and winning track record means you have a law firm that makes workers’ compensation work for you.

For more information about your options in the workers’ compensation process, or to schedule an initial consultation with one of our knowledgeable attorneys, contact our office online or at (888) 675-7607.