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What To Do If Surgery is Denied by Workers' Comp

Team of surgeons performing surgery in operation theater. Group of doctors in hospital operating theatre.

A workers' comp attorney can fight for the medical treatment you need to facilitate your recovery.

When an employee is injured on the job, swift access to quality healthcare is vital for their recovery and overall well-being. Prompt medical attention can help prevent further complications, minimize long-term damage, and facilitate a faster return to work.

Workers' compensation is designed to provide financial support and medical benefits to employees who suffer work-related injuries or illnesses. Within this framework, coverage for surgery is an essential component. In situations where surgery is deemed necessary and reasonable for treating a work-related injury, workers' compensation should cover the costs associated with the procedure, including pre- and post-operative care, anesthesia, medications, and other related expenses.

Unfortunately, injured workers often find themselves in difficult situations when workers' compensation denies necessary surgical interventions. When workers' comp denies surgery, it creates additional challenges and frustrations for injured workers who are seeking proper medical care to recover fully and resume their everyday lives and livelihoods.

Injured workers need to be aware of their rights and understand the actions they can take to navigate this complex situation. If your surgery for a work injury has been unjustly denied, a workers' compensation attorney can provide the necessary support to challenge the decision and advocate for your rights.

Types of surgeries covered by workers' compensation

Again, workers' comp is designed to cover all reasonable and necessary treatment or work-related injuries or illnesses. In principle, this means any type of surgery can be covered by workers' compensation if it is reasonable and necessary to treat a work injury. Work-related injuries may require surgeries such as:

It's important to note that the scope of coverage extends beyond just the surgical procedure itself. Workers' comp should cover the full range of reasonable and necessary medical expenses associated with the surgery and its aftermath. This includes pre-and post-operative care, anesthesia, medication, medical devices, follow-up visits, rehabilitation, and so on. Moreover, there are no out-of-pocket expenses such as co-pays or deductibles; the full cost is covered.

In addition to covering surgical expenses, workers' compensation should also provide partial wage replacement for the duration of the recovery period when an employee is unable to work due to the surgical procedure. This coverage extends to cases where the injured worker needs to take on a "light duty" role with reduced pay as a result of the surgery.

Common reasons for denial

When faced with a denial of surgery by workers' compensation, it is common for the insurer to dispute the "reasonableness and necessity" of the procedure. To respond effectively,  medical evidence supporting the need for surgery is crucial. This may involve obtaining expert opinions, medical records, diagnostic tests, and any other relevant documentation that demonstrates the vital role surgery plays in treating your work-related injury. Compiling a strong body of evidence can strengthen your case and challenge the denial.

Workers' comp may propose alternative treatments in place of surgery. If you believe surgery is still the most appropriate course of action, you can present your case based on medical expertise and the expected benefits surgery offers compared to the suggested alternatives.

Workers' comp insurance companies may also require second opinions from doctors who might be biased toward their perspective. And in some instances, they may deny surgery by asserting that the injury is not work-related.

Relevant documentation can support your claim, including incident reports, witness statements, medical records, and other evidence that substantiates the work-related nature of your injury. By presenting compelling evidence, your attorney can challenge the denial and demonstrate that your injury deserves coverage under workers' compensation.

When to contact a workers' comp attorney

Navigating the legal landscape surrounding workers' comp denials requires a deep understanding of the complex regulations and procedures involved. Without proper knowledge and experience, it is nearly impossible for injured workers to effectively advocate for their rights and challenge a denial on their own. Seeking legal representation ensures that you have a professional who comprehends the complexities of workers' compensation laws in New York and can guide you through the whole process.

At Pasternack Tilker Ziegler Walsh Stanton & Romano LLP, we protect the rights of hard-working New Yorkers who have suffered workplace injuries and illnesses. For over 80 years, our firm has been committed to providing aggressive representation and ensuring injured workers receive the benefits they deserve.

If you or a loved one has faced a denial of surgery by workers' comp, we urge you to take action and seek our assistance. Our compassionate attorneys will fight tirelessly to protect your rights and pursue the necessary medical treatment for your recovery. With our law firm by your side, you can have peace of mind knowing that you have a trusted legal team supporting you every step of the way.

Don't let a denial of surgery hold you back from receiving the care you need. Contact us today to schedule a free consultation and learn how we can help you.

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