Why Was Your Workers’ Comp Surgery Denied, and What Do You Do Now?

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.

Construction worker holds his head on step of demolished building. Farrin facts about denied surgery

Who Can Deny Me Surgery Under Workers’ Comp?

In North 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.
  2. 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.
  3. 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.
  4. 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. 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.

Learn more about the 3 phases of the Appeals Process

Learn more about the North Carolina Industrial Commission

We may be able to help you win your appeal. Contact us at 1-866-900-7078 for a free case evaluation.

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About the Author

Casey Day practices workers’ compensation law for the Law Offices of James Scott Farrin and has experience on both the defense and plaintiff sides. She is licensed in North Carolina, South Carolina, and Virginia. Casey was honored on the “Best Lawyers: Ones to Watch” list for Workers’ Compensation Law – Claimants by Best Lawyers in America for 2021 and 2022.a Casey regularly contributes her time to helping the underserved through pro bono legal work.

aFor “Ones to Watch” standards of inclusion, visit bestlawyers.com.

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