As I try to keep this blog updated, I spend part of each day reviewing the search terms that readers are using as they search for information about Minnesota work comp issues. Among the most common search terms I see are searches like this:
“The workers’ compensation insurance company won’t pay for surgery-what can I do?”
“The work comp IME doctor says I don’t need surgery-can I fight it?”
“Who decides if work comp has to pay for my surgery?”
This is one of the more common disputes that I deal with on a weekly basis in my work comp practice here in northern Minnesota. Even if your claim has been accepted by the work comp insurance company and they are paying wage loss or other benefits, they still might refuse to pay for a surgery recommended by your treating doctor or specialist. At that point, you really don’t have any choice but to hire a lawyer and file a request for a medical conference or hearing.
How can the insurance company deny your doctor’s surgical recommendation?
In general terms, every medical dispute comes down to three factors. The factors are whether the treatment or procedure is:
- necessary, and
- related to the work injury
If the insurance company questions whether the proposed surgery is reasonable, necessary or related to your admitted work injury, they have the legal right to get their own medical opinion before deciding whether to approve the surgery. This medical opinion is called an Independent Medical Exam (IME). (For more information about an IME, you can see this previous post- “An Independent Medical Exam in Your Minnesota Work Comp Case”)
Once the insurance company gets a report from the IME doctor, they will decide whether to approve or deny the surgery (or any other medical procedure which might be in dispute).
What are my options once the surgery is denied by the insurance company?
If you have an attorney, he will handle all of this for you. He will generally request a report from your surgeon explaining what surgery has been recommended, why the surgery is necessary and how it is related to your injury. Sometimes, the only dispute is whether the surgery is really necessary, particularly if there are other more conservative medical treatments which have not yet been tried ( physical therapy, injections, etc).
In other cases, there may be a dispute as to whether the recommended surgery is related to the work injury. The IME doctor will often give an opinion stating that your work injury was only a” temporary aggravation “ of a pre-existing condition, and that the surgery is therefore not related to the work injury, but rather to your pre-existing condition. ( The burden of proof is on the employee to establish a medical claim, so you will need some medical support or explanation from your treating physician if that is the issue)
There are also treatment parameters which require certain conditions or prior treatment to be done before a surgical procedure is authorized under the work comp law. An insurance company may sometimes rely on these to deny prescribed surgery or treatment.
What are the procedures for getting surgery approved?
Generally, a surgical dispute will require a formal hearing before a work comp judge. The process begins with getting the dispute “certified”, after the insurance company has an opportunity to approve or refuse the request for surgery. Once the insurance company has refused to authorize the surgery, the dispute is officially “certified” and you may request a hearing to have the matter decided. At the hearing, a compensation judge will listen to your testimony and review all the medical records and reports before making a decision. Either party may appeal the decision, which may delay the matter even longer.
While you are not required to have an attorney to file a request for a medical hearing, it would generally be a bad idea to represent yourself. The insurance company will have an attorney representing them, which would put you at a very serious disadvantage when it comes to knowing the rules and procedures of presenting a case to a work comp judge.
Can I just have my health insurance pay for the surgery?
This is an option under certain circumstances. Obviously, you need to have health insurance to make this an option. In addition, most health insurers will not pay medical treatment related to a work injury unless the work comp insurance company has specifically denied authorization for the treatment or refused to pay medical bills. At that point, the health insurer will generally step in and pay the bills while you continue to pursue the claim within the work comp system. If you ultimately win or settle the medical dispute, the work comp insurance company will have to reimburse your health insurance and also reimburse you for any out-of-pocket medical expenses related to the disputed medical procedure.
Are there advantages to having work comp pay for the surgery instead of my health insurance?
Absolutely. There are a number of reasons why you are much better off having work comp pay for your surgery, rather than your health insurance. Some of these reasons are:
- work comp pays 100% of the medical bills, with no co-pays or deductibles
- work comp will usually have to pay you wage loss benefits until you can return to work after the surgery
- work comp will reimburse you for your medical mileage
- you may be entitled to a permanent partial disability (PPD) payment if it is work comp
- the injury/surgery will now be “on the books” as work comp, which protects you if you have a flareup or more problems later on
If the work comp insurance company refuses to authorize a recommended surgery, or seems to be delaying a decision or otherwise “dragging things out”, it would be a good idea to consult an attorney. Sometimes, all it takes is the involvement of a good work comp attorney to get the insurance company’s attention and make them stop screwing around with you and your claim.
A good attorney will know what medical support is needed to take a dispute to a hearing and will be able to get the records and medical reports necessary to get the surgery approved. (Assuming you are fortunate enough to have a doctor who is cooperative and supportive of your work comp claim – unfortunately, not all doctors are. If interested, see this previous post- “Choosing a Doctor for your Minnesota Workers’ Compensation Claim”)
If you have questions about a medical dispute, or any other aspect of a Minnesota work comp claim, feel free to contact me at any time, for an absolutely free consultation. I will always try to answer your questions, give you my honest opinion about whether you need a lawyer and let you know if there is something I can do to help you. I regularly speak with people who don’t necessarily need a lawyer and I tell them just that.
How much does it cost to hire a lawyer for a work comp claim? See this post
I hope you have found this information helpful. If you have, please share our website or blog with anyone you know who may have questions about a work comp claim in northern Minnesota.
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