If Workers’ Comp Surgery Is Denied, What Happens?

If you’ve been injured at work, your employer’s insurance company must generally provide you with all medically necessary treatment. Seems like a straightforward concept, right? Unfortunately, questions about what’s necessary and who should provide it arise for injured workers every day. And that can be a big problem if your doctor has recommended surgery, but the insurance company disagrees. Here’s what to know, and what to do.

Who Can Deny Me Surgery Under Workers’ Comp?

In North Carolina and South Carolina, the workers’ compensation insurance company has the right to direct your care. That includes denying surgery at their discretion. What’s “necessary” is for a doctor to decide — but the insurance company’s doctor may have a different opinion than your surgeon.

Why Would They Decline to Cover My Surgery?

The insurance carrier may deny your surgery for one of these common reasons:

1. They say the surgery isn’t necessary. They may claim that the surgery isn’t needed to resolve your condition or that it won’t do anything to improve your injury.

1. They say the surgery isn’t treating a work-related injury. The insurance carrier may deny that your injury occurred at work. Or, they may accept that your injury occurred at work, but argue that this surgery is really for a different, unrelated injury.

1. They say your doctor isn’t authorized. The insurance carrier wants you to receive treatment from their preferred doctors — doctors with whom they feel comfortable and have an existing financial relationship. If you receive needed treatment for a work injury, but it’s from an unapproved doctor, the insurance carrier will likely deny your claim.

1. They say you haven’t followed doctors’ orders. The insurance company may agree to surgery only when all other options have been exhausted. If you were supposed to try a strict physical therapy program first, for example, but didn’t, the insurance company will likely deny you coverage for surgery.

Insurance Companies Are Protecting Their Own Interests

The reality is that for-profit insurance companies want to make profit – and they keep more profit by paying you less. Unsurprisingly, surgery is expensive. Let’s look at one example.

One of the most common conditions leading to workplace injury is overexertion. About a third of missed days from work can be blamed on injuries resulting from overexertion like lifting, carrying, and similar activities.

Among the most common injuries resulting from overexertion are back injuries. While some back injuries are mild and easy to recover from, some can be quite debilitating — and may require surgery. The most common type of back surgery is spinal fusion, which can cost about $100,000.

Here’s what all that means: If the insurance company can find a reason to deny your surgery, they very well may deny your surgery.

What Should I Do if My Workers’ Comp Surgery Claim Is Denied?

If your surgery is denied, there is an appeals process. In North Carolina, your attorney can help you request a hearing with a judge from the North Carolina Industrial Commission (NCIC). The NCIC is responsible for administering workers’ comp in North Carolina and they can compel the insurance company to cover your surgery. In South Carolina, the South Carolina Workers’ Compensation Commission (SCWCC) administers the workers’ comp system in the state. Your attorney can help you request a hearing if your surgery claim is denied — first with a single commissioner and, if necessary, with the full Commission.