Denying workers’ compensation claims is not a new thing for employers’ insurance companies. Sometimes, the denials are based on legally valid reasons, like questionable inconsistencies in the information the insurer requires to establish facts in a claim.
Other times, insurers may deny a claim based on half-truths or inaccurate information in the hopes that a claimant will give up. Don’t let this happen to you.
If a workers’ comp denies your surgery related to a work injury, the denial isn’t final. You can appeal, but you will need reliable legal guidance from an experienced workers’ compensation attorney.
David Aylor Law Offices wants you to understand why your workers’ compensation claim can be denied, and what to do to fight for your right to benefits if you need surgery for a job-related injury.
Types of Work Injuries that Might Require Surgery
Workplace accidents may cause serious injuries that may require surgery. These injuries vary depending on the individual and the work environment. Here are common workplace injuries that might require surgical procedures:
- Back injuries (dislocated or broken spine bones)
- Bone fractures
- Traumatic brain injuries
- Third-degree burns
Surgery costs vary depending on the severity of sustained wounds, which determines the surgical procedure used. Surgery can increase the settlement amount if you are entitled to workers’ compensation.
However, this will depend on the type of surgery and the likelihood of future complications. Complex surgeries are more expensive, so they increase compensation by more than minor procedures.
Surgery and non-surgical hospital expenses (related to workplace injury) are usually included in the settlement. A workers’ compensation attorney can help you pursue the highest possible compensation amount you’re rightfully entitled to.
Why Would Workers’ Comp Deny Your Surgery?
You were hurt at the workplace. Why would your workers’ comp refuse your surgery?
Workers’ compensation claims are rarely as simple as getting financial benefits after you get injured on duty. As with all insurance claims, workers’ compensation depends on certain rules. In most cases, your claim must meet the criteria below for workers’ compensation to cover your surgery:
- Your occupational injury and medical needs must be directly related. If you can’t prove that the injury resulted from the workplace incident, your employer’s insurance company may deny your compensation claim.
- You must seek treatment from a doctor approved by your employer. In South Carolina, your employer retains the right to decide which physician will treat your workplace injuries.
Your employer’s insurer may not cover the medical expenses if you don’t seek treatment from an employer-approved physician. However, you can file a hearing if a second opinion from your doctor reveals that surgery is necessary, yet your employer’s insurer denies your claim.
Workers’ compensation claims that don’t meet the above criteria may be denied in South Carolina.
Below are other possible reasons your workers’ comp can deny your surgery. Depending on your specific situation, these reasons may be invalid or be mere excuses the insurance company uses to avoid covering your surgery costs.
Your employer (or their insurer) believes you don’t sustain any injuries
Some occupational injuries may not show up in medical scans. Some internal fractures and muscle injuries may be difficult to detect in the initial checkup, even with high-quality medical images. When this happens, your employer might incorrectly think you exaggerate your injuries.
As a result, the insurance company denies your workers’ compensation claim when you truly need the money to cover medical expenses (resulting from work-related injuries). A second opinion from a certified doctor and legal guidance from an experienced attorney can help you get the compensation you are genuinely eligible for.
The insurer thinks you weren’t sober when the workplace accident occurred
Your employer or the insurance company might deny your claim if they believe that the influence of alcohol or drugs contributed to your workplace injury. Employers require workers to take a drug or alcohol test after a job accident.
However, these tests must be done immediately or within an acceptable timeframe to be legitimate. The claim denial might be based on invalid or inaccurate test results if you are tested the following day after you went home and had a drink.
The employer claims that you didn’t report your injuries on time
Workers’ compensation laws in South Carolina require employees to report job-related injuries to employers within 90 days of the workplace accident. If you did so and believe the insurance company unfairly refuses to cover the surgery costs, taking legal action might be the only way to fight for what you’re entitled to.
Your employer (or their insurer) claims that your injuries are not work-related
When your employer or the insurance company thinks you got injured elsewhere other than the workplace, they may dispute your claim and deny compensation.
Remember, you might still be entitled to compensation even if you had a pre-existing health condition aggravated by a workplace injury. So, don’t lose hope if the workplace accident wasn’t the original cause of your current injuries. A competent lawyer can help prove that an incident in the workplace caused or worsened your current health condition.
Workers’ Comp Denied Surgery: What Should You Do?
An insurer will count on you to give up after turning down your workers’ compensation claim. However, don’t stop pushing for the compensation you believe you are eligible for. Claim denial by the insurance company isn’t the final say concerning workers’ comp benefits.
If workers’ comp is refusing your surgery, you need to act first to protect your right to benefits you’re entitled to. You can challenge claim denial by filing a case and requesting a hearing, but you’ll need solid evidence and convincing testimony to stand a chance.
You can appeal a denial on your own, but this might be the biggest mistake you will ever make. You need the workers’ compensation to pay for surgery, so you should only use the best opportunity for success to handle claim denial.
The best way to increase your chances of overturning a claim denial is to hire an experienced workers’ compensation attorney. A lawyer can analyze why the insurance company denied your request and challenge their decisions with a solid defense strategy.
Why You Need a Workers’ Compensation Lawyer When You Surgery’s Been Denied
You’re entitled to workers’ compensation benefits if you get injured when working. Sadly, just because you qualify for compensation doesn’t mean you will get the benefits. You will need legal help. Here’s how a lawyer supports your case and helps get things done correctly.
1. Fight for your rights to workers’ compensation
The insurance company may not always have your best interest when investigating your workers’ compensation claim. They’ll use possible means to deny your claims or give you the least possible settlement amount.
An attorney is on your side, using your best interests as a guiding compass. An insurer may deny your claim on the grounds of insufficient medical evidence. A lawyer can help prove that you sustain a work-related injury.
2. Reliable legal advice
When narrating how you got injured, the details you include can make or break your case. An experienced attorney’s advice ensures you don’t contradict yourself when explaining the incident.
3. Stay on top of deadlines and speed up the process
Your workers’ comp case can drag on for months if you don’t know what steps to follow in your case. With a deep knowledge of workers’ compensation laws, a lawyer helps you file your case and dig up evidence faster to speed up the process.
Contact an Experienced Workers’ Compensation Attorney in Charleston, SC
If your workers’ compensation claim denies your surgery and you believe you have the right to medical benefits, contact David Aylor Law Offices for a free case evaluation.
Workers’ Comp for Surgery FAQs
Under what circumstances can workers’ compensation deny your surgery?
- When the insurer establishes your injury that requires surgery isn’t work-related
- When you seek medical help from a doctor who your employer doesn’t verify
- When there are other cheaper medical solutions for your injuries
Is an insurer’s claim denial final?
No. You can appeal with the help of an experienced attorney to ensure you follow the right legal procedures and avoid contradicting yourself.
Who provides medical care if your injuries are work-related?
A doctor that your employer approves. Workers’ comp may not cover your surgery if you receive treatment from any other doctor without consulting your employer.