You’re hurt at work. It’s a serious injury, and it isn’t going to heal on its own. You need surgery.
Getting the surgery that you need should be simple. Then, you find out that the insurance company is denying your claim. What can you do?
If your workers’ comp surgery has been denied, there are things you can do to fight back. Our Atlanta workers’ compensation lawyers explain what happens if your workers’ comp surgery is denied.
Coverage of Surgery in Georgia Workers’ Compensation Benefits
Is surgery included in Georgia workers’ compensation benefits?
Yes. Necessary surgery is included in Georgia workers’ compensation benefits.
Workers’ compensation covers injuries “arising out of and in the course of the employment.” (Georgia Code § 34-9-1(4)). An employee has the right to medical care that is reasonably required and likely to effect a cure, give relief or restore the employee to suitable employment. (Georgia Code § 34-9-200).
Among the types of medical care that a person may receive are medical attention, surgical, hospitalization, surgical supplies, prosthetic devices and aids, and other treatments. Id.
To the extent that surgery is likely to provide a medical benefit or occupational rehabilitation, the injured worker is entitled to it.
What are some reasons that workers’ comp surgery may be denied?
Make no mistake – workers’ compensation insurance companies operate to make a profit. They collect premiums and make their profits when they minimize the benefits they pay. They have all kinds of excuses for denying workers’ comp surgery.
Here are some reasons that workers’ comp surgery may be denied:
- There isn’t any medical benefit to having the surgery. Surgery may be denied on the basis that it is unlikely to cure, provide relief or help restore the worker to suitable employment.
- Maximum medical improvement has already been reached. Having the procedure isn’t likely to improve the victim’s health or ability to work.
- The doctor isn’t authorized. The injured worker didn’t use an authorized care provider as required by workers’ comp laws.
- The injury isn’t work-related. Workers’ compensation pays for treatment for injuries in the course of employment. The insurance company may deny payment, saying the injury is not work-related. They may say that it’s a pre-existing condition or that the victim received the injury in another way besides their employment.
- You were not following the doctor’s orders. Surgery may be denied if the person does not follow their care plan, including attending appointments and instructions for at-home care.
- You weren’t hurt. The insurance company may say that there is no injury to treat.
- There are missed deadlines. To receive workers’ compensation benefits, including surgery, the victim must comply with filing deadlines.
- The injury happened under the influence or by intentional misconduct. Workers’ compensation may be denied if the injury results from alcohol or drug use or intentional misconduct on the job. This is true even when surgery is required.
Just because the insurance gives a reason for denying the surgery doesn’t make it right. Remember, insurance companies work to minimize their payments and maximize their profits. If they wrongfully deny your surgery, you can fight back.
Fighting Workers’ Compensation Surgery Denial
There are three ways to fight a workers’ compensation surgery denial:
- Call the insurance provider
- Request a show cause hearing before a workers’ compensation judge
- File a WC-14 Notice of Claim
Call the insurance provider
Sometimes, getting approval for the surgery is just a matter of talking to the insurance provider. They may be missing information, or there may be confusion. This rarely works, but it’s possible to quickly clear up the denial of the surgery by asking the insurance company to review the situation.
Have a Request for Authorization (WC-205) teleconference with an Administrative Law Judge
The Georgia Workers’ Compensation Law creates standards for resolving disputes over authorized care for injured workers. If you are in a situation where the treatment provider has recommended surgery and provided documentation, and the employer/insurer has failed to authorize the surgery, you can invoke WC-205 to request a show cause hearing before an Administrative Law Judge. You may also file a PMT (Petition for Medical Treatment).
The hearing is held by telephone. A ruling may be made to authorize the treatment even if the employer/insurer does not attend. Instead of attending, the employer/insurer may authorize the surgery. If they authorize the surgery, they must complete the paperwork. It is very important that the employee attend the hearing with their attorney.
The insurance company may object or appeal. A hearing will be held on an objection.
Who has the burden of proof for the hearing?
If the employer claims the surgery is unnecessary, they have the burden of proof. If the denial is based on the surgery not being authorized or for a work-related injury, the employee has the burden of proof.
Filing a WC-14 Request for Hearing
A WC-14 Request for Hearing takes your case before an Administrative Law Judge. At the hearing, the judge decides what benefits you should receive. Your case may proceed to a hearing, or it may be resolved by settlement between the parties. There may be a mediation session to encourage the parties to reach a resolution.
If you proceed to file the WC-14 hearing request, the hearing may address any contested issues. If you’re considering a settled resolution, it’s important to understand whether future medical care will be covered and what you are agreeing to when you accept a settlement. A settlement may be a lump sum or structured. Of course, you don’t have to accept a settlement. Our lawyers can help you evaluate all the options and answer your questions.
As an injured worker in Georgia, you have the right to change doctors once. You must still use a care provider that is on the list of authorized caregivers provided by your employer. However, it can still be a helpful option to change doctors if you feel that your treating healthcare professional is not doing a good job.
Lawyers for Workers’ Compensation When Surgery Is Denied
Our workers’ compensation lawyers are not afraid to take challenging cases and fight for justice. When you need surgery, you need help quickly. Our lawyers are serious about helping victims pursue their benefits.