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Workers comp has refused to pay for my surgery, what should I do?

If workers compensation has refused to pay for surgery you have a right to pursue approval and payment of the surgery.  This can be done through a Medical Request or Claim Petition filed with the Office of Administrative Hearings. Our office and work injury attorneys can help you with your claim for surgery.

After your provider has submitted a request for approval to the workers compensation insurer they either must admit, deny or request a  second opinion such as through an independent medical examination.  In the cases of surgery, they are obligated to have an independent medical examination “IME” within 45 days of the request for surgery. The insurer may wait to deny the claim until after independent examination. During this time between the surgery request and receipt of the IME you may have to wait to have the surgery. You can attempt to put the surgery under your own health insurance but in most cases the health insurer will want a “formal denial” If you are able to get approval through your private health insurer, depending on whether your attorney files a claim or if workers’ compensation agrees to pay, your health insurer can seek reimbursement for payment. 

So what do I do if I am not getting the surgery I need approved?

In most cases, it may be beneficial for you to sit down with a lawyer to discuss your legal options and whether or not a claim would need to be filed to get the treatment approved.  There are, however, things that you can do on your own without the assistance of a lawyer to help you get the necessary treatment, including:

• Make sure that your provider has submitted the appropriate request to the insurance company.

• Contact the insurance company to confirm that they have the appropriate information about the surgery.

• Determine whether or not an independent medical examination has been scheduled.  If an adjuster is dragging their feet in scheduling one, it may be in your best interest to contact the Department of Labor and Industry to assist in getting the examination scheduled so a determination can be made.  They can be reached on the Workers’ Compensation hotline.

If any of the above is unsuccessful or if you have already been told that the treatment is denied, you should contact a workers’ compensation lawyer in order to discuss your case.  The lawyer will need to gather all of the appropriate records to file a Medical Request or Claim Petition on your behalf.  The attorney will also need to make sure that the appropriate medical support is gathered, including an opinion as to why the recommended surgery is reasonable, necessary and causally related to the work injury.