What Happens If Workers’ Comp Denied Your Surgery?

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For some injured workers, getting workers’ compensation benefits is only part one of your story. Workers’ compensation benefits are intended to pay for the complete cost of medical expenses to treat your injury.

However, the insurance company must pay the claim, and it often fights when it does not want to pay. It may argue that the surgery is not medically necessary for your condition. Like everything else with workers’ compensation, the insurance company does not get the final say. You have the right to appeal any coverage denial and have someone who is actually objective make the decision.

Ideally, you can discuss the denial with the insurance company and go through an internal appeals process. They can reverse their initial decision and decide to cover the surgery. North Carolina law gives a process that you can follow if you are getting nowhere with the insurance company.

Contact our workers’ compensation lawyers today to discuss the complexities of your case.

The Insurance Company Will Act in Its Own Financial Interests and Not Your Medical Interests

First, you cannot expect the insurance company to act in your interests, even though they may have a legal obligation to pay the medical costs. Workers’ compensation insurance is provided by for-profit companies that are more interested in their own finances than your health.

There may be several reasons insurance company may try to deny your surgical procedure, including:

  • They claim that the surgery is not medically necessary.
  • They believe that the surgery treats a pre-existing condition instead of a work-related injury.
  • They say that you have not followed the doctor’s orders, and the surgery could have been unavoidable had you stuck with your medical treatment.

One of the most common types of surgery for which insurance companies try to deny coverage is back surgery. Your work duties may have caused you to overexert yourself, requiring an expensive procedure to fix the damage. Back surgeries can have costs that reach six figures because of their complexity.

Insurance companies like to deny coverage for back and spinal surgeries. Any type of treatment that may seem like it is not standard “by the book” medical care may be denied by the insurance company.

Workers’ Compensation Benefits Do Not Cover All Medical Conditions

It is important to remember that workers’ compensation is not the same as health insurance. The focus of your treatment is the work-related injury and helping you recover. You may not choose your own doctor for medical treatment.

If you suffer from other conditions, treatment for those is best funded by your own health insurance. This treatment is separate from workers’ compensation benefits. You can expect the insurance company to draw a hard line if they believe you are asking them to pay too much. They may err on the side of denying claims, knowing that you will need to fight them.

You Have the Legal Right to Appeal a Coverage Denial

Whatever the reason, you can get an objective decision from a third party, as opposed to an edict from a biased insurance company. The same North Carolina Industrial Commission that gets involved when your workers’ compensation claim has been denied in the first place can also hear your appeal if the insurance company has denied certain medical coverage.

The Industrial Commission administers the workers’ compensation program, and it has a complex set of tables that dictates what services are to be reimbursed and at what rates.

If the insurance provider has denied coverage for a surgery that your doctor believes you need, you can begin the appeals process.

You will need to appeal the denial within a certain amount of time, and you have every interest in beginning the process quickly because the medical care that you need will be at issue.

Workers’ Compensation Hearings About Surgery Are Complex and Technical

If you cannot resolve your dispute, the North Carolina Industrial Commission will hold a hearing in front of an administrative law judge, who will make the ultimate decision regarding the insurance company’s denial. Presumably, your attorney will present medical evidence that shows that both the surgery is to correct a work-related illness and that it is medically necessary.

Any hearing that considers your appeal will be one that can be scientifically and medically complex. You will need to make medical arguments and work with doctors who can testify on your behalf. You should not attempt to appeal any coverage denial on your own. Surgical procedures are extremely expensive, and the appeal may mean that there are tens of thousands of dollars or more at stake.

An experienced workers’ compensation attorney knows how to most effectively present your appeal to the North Carolina Industrial Commission in the hopes of obtaining a favorable resolution. There is too much at stake to proceed without an attorney. Once you lose an appeal, it is harder to reverse the decision in subsequent appeals.

Contact a Wilmington Workers’ Compensation Attorney Today

At Horton & Mendez Injury Attorneys, we know the ins and outs of the North Carolina workers’ compensation system and are prepared to fight for you when the insurance company denies your rights. They can answer the question of what to do if workers’ comp denied surgery.

Your first step is to speak with an experienced lawyer to discuss your case. To schedule an initial consultation, you can call us at (910) 668-8067 or message us online today.

Workers’ Compensation FAQs

How long do I have to appeal the denial of workers’ compensation benefits?

You have 14 days from the receipt of the denial notice to inform the North Carolina Industrial Commission that you intend to appeal.

How is a workers’ compensation attorney paid?

Workers’ compensation lawyers are paid on a contingency basis. You do not owe that money unless you achieve a successful case resolution. You do not pay money upfront.

Can I get worker compensation coverage if my injury did not come from an accident?

Yes. You can receive benefits for a work-related illness or an injury that was caused by overexertion on the job.

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