Workers’ Compensation Lawyer San Diego, CA

What To Do if Surgery is Denied by Workers' Comp

Medical team in the operating room, dark background.

If you suffered a work-related injury that requires surgery, you could be facing high medical expenses and months of recovery. The good news is that workers' comp benefits in California can cover the cost of surgery and other reasonable and necessary medical procedures.

Sounds simple, right? Unfortunately, getting the financial benefits you're entitled to isn't as easy as it should be, especially when dealing with a work-related injury requiring surgery.

That's why it's crucial to have an experienced workers' compensation lawyer by your side. Robert A. McLaughlin, APC helps injured workers navigate the California workers' comp system. Our dedicated team is here to ensure your rights are protected, your medical expenses are covered, and you receive the compensation necessary for a successful recovery.

Don't let the challenges of a workers' compensation claim add to the stress of your injury. To see how we can help you, contact us today to schedule a free case review.

What types of workplace accidents require surgery?

Workplace accidents can lead to a wide range of injuries, some of which may require surgical interventions to restore health and functionality. Common work-related injuries that often require surgery include:

  • Broken bones: Bone fractures often occur due to falls and accidents involving heavy machinery or construction. These injuries often require open reduction and internal fixation (ORIF) for the bones to realign and heal.
  • Spinal cord injuries: Serious work-related spinal injuries often include herniated discs, vertebrae fractures, or compression injuries. Your doctor may recommend surgery to reduce nerve compression and stabilize the spine.
  • Tendon and ligament tears: Tendon injuries in the knees, shoulders, ankles, or hands often occur due to repetitive motions. Surgical restoration is often conducted through arthroscopic procedures.
  • Severe head injuries: High-risk occupations may expose workers to head injuries. Severe head trauma often calls for surgical interventions, such as craniotomy or decompressive craniectomy.
  • Burns: Burns are very common in kitchens, boiler rooms, chemical labs, and other industrial settings. Severe burns often require skin grafts to fix the damaged tissue. In some cases, severe burns require reconstructive surgery.
  • Crush injuries: Occupations involving heavy machinery or construction can expose workers to crush injuries. These injuries can sever limbs and other affected areas. Surgical intervention may be needed to reconstruct and rehabilitate the affected regions.
  • Eye or face injuries: The eyes and face are vulnerable, especially in occupations involving heavy machinery. In some cases, reconstructive surgery, corneal transplant (Keratoplasty), or cataract surgery may be necessary.

What types of surgery does workers' compensation cover?

Workers' comp covers a variety of surgeries deemed necessary and reasonable. Some common surgical procedures include:

  • Orthopedic surgical procedures: This surgical category aims to fix fractures and torn ligaments. These include arthroscopic surgery, ORIF, and spinal surgeries.
  • Reconstructive surgery: This type of surgery is often required after facial injuries and severe burns.
  • Carpal tunnel release surgery: If you develop carpal tunnel syndrome, you may require carpal tunnel release surgery.
  • Amputation surgeries: Amputation surgeries are often necessary for the loss of a limb or body part.
  • Neurological surgical procedures: Craniotomies or decompressive procedures often treat severe head and spinal cord injuries.
  • Cardiovascular surgical procedures: When a heart condition or cardiovascular injury occurs due to the nature of a job, you may need coronary artery bypass grafting (CABG) or angioplasty.
  • Ocular surgeries: These surgical procedures treat eye injuries caused by chemical exposure and simple workplace accidents.
  • Surgeries to treat infections and related complications: You may need wound debridement or abscess drainage for work-related infections or other similar complications.

Why would workers' comp deny my surgery?

While workers' compensation covers most types of medical treatment, it could deny your surgery for many reasons, such as:

  • The insurance company deemed your surgery unnecessary, as opposed to an alternative treatment: Workers' compensation may deny surgery if the insurance company believes that there are less invasive or less expensive treatment options available. They may require a second opinion from a different medical professional to assess the necessity of the surgery.
  • You weren't able to prove that your injury was work-related: To qualify for workers' compensation, your injury must be directly related to your job. If you couldn't sufficiently demonstrate the connection between your injury and your workplace, the surgery may be denied.
  • You didn't file your claim soon enough: Timeliness is crucial in workers' compensation claims. Failing to report your injury promptly or delaying the filing of your claim can give the insurance company a reason to deny surgery coverage.
  • The workplace accident wasn't reported or documented: If there is no official record of the workplace accident, such as an incident report or witness statements, the insurance company may question the validity of your claim, including the need for surgery.
  • You didn't get prompt medical attention or keep records of your medical visits or receipts: Consistently seeking medical attention and maintaining detailed records of your treatment can strengthen your case. Without proper documentation, the insurance company may be skeptical about the urgency of your surgery.
  • Your application was incomplete or had errors: Errors or omissions in your workers' compensation application can lead to delays or denials. It's essential to fill out the necessary forms accurately and completely to avoid issues with your surgery coverage.

Remember, filing a workers' compensation claim can be complex, and insurance companies may take advantage of unrepresented claimants. Consulting with an attorney who has extensive experience in workers' compensation cases can help you navigate the process, ensuring that you meet all requirements and have the best chance of approval for necessary surgery.

Contact a workers' comp attorney to protect your rights

Don't let denials or delays in surgery coverage discourage you. Contacting an experienced workers' compensation lawyer can make a significant difference in your case, ultimately helping you obtain the medical treatment and financial support you rightfully deserve.

If you sustained a severe injury on the job that requires surgery and workers' comp has denied your claim, it's important to know your potential legal options. Contact Robert A. McLaughlin, APC today to get answers to your questions and a clear understanding of your rights. We have offices in San Diego, Chula Vista, and Temecula.

Categories: Posts