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What to Do if Workers Compensation Denies Your Surgery

In some cases, the insurance company may deny certain procedures or treatments after a work-related injury.

Worker’s compensation is supposed to cover all medical costs that relate to your work injury or illness. However, in some cases, the insurance company may deny certain procedures or treatments.

Can they do that? What would be the reason?

work injury surgery denied

Can the Insurance Company Deny Treatment?

This is a difficult question to answer, as it works on a case by case basis. Technically, the insurance company should have no say in your treatment. The only one who can decide which treatment or procedure you need is your worker’s comp doctor.

Still, how are they able to deny something your doctor deems is relevant to your treatment? Well, it, unfortunately, boils down to cost. The insurance company may refuse to pay to a particular treatment if they deem is either unnecessary or if there is an alternative, cheaper procedure that would bring the same results.

How Would They Know?

The insurance company adjuster may not have any medical expertise to know what is and isn’t a relevant procedure for injured workers, but they do collaborate with medical experts. So, they could present your case to one of the said experts and ask for their opinion, especially in regards to more expensive procedures such as surgery.

If their experts deem you do not need said surgery, since there are other forms of treatment available (that would also cost less), the insurance company will use their opinion as an argument your surgery is unnecessary, even if your worker’s comp doctor thinks otherwise.

What Can You Do?

Medicine is often not a black and white industry, and it is possible for 3 doctors to have 3 different recommendations for the same case. However, in the context of workers’ comp claim, you want to ensure you are getting the best medical care possible, even if the insurance company believes it is too expensive.

So, if your surgery is denied, does that mean it’s the end of the road? Not exactly. For one thing, your worker’s comp doctor may revise your course of treatment to stay within the lines of what the insurance company wants, but that’s not exactly ideal, since you may actually benefit more from the surgery than its alternative.

The safest way to proceed in these instances is to reach out to a St. Louis worker’s compensation attorney for help. They can help make your case and bring additional evidence to showcase the surgery is your best course of treatment, possibly even by bringing in other medical experts to make this case on your behalf.

Even if they cannot reach an agreement easily, they still have additional legal options, such as initiating a mediation process or even taking your case in front of an administrative judge.

St. Louis Work Injury Lawyer

Don’t get discouraged if your surgery gets denied. Reach out to an experienced work injury lawyer today to learn more about your legal rights and ensure they are protected.

Speak With a Workers Comp Attorney

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Updated: September 28, 2020