Various work-related injuries necessitate surgical intervention, ranging from fractures and soft tissue injuries to internal organ damage and repetitive stress ailments like carpal tunnel syndrome. In the aftermath of such injuries, employees often find themselves pondering a crucial question: “How long does workers’ comp have to approve surgery?”
In most cases, covering surgical costs for job-related injuries involves filing for workers’ comp, a system designed to encompass all types of work-related injuries and their requisite treatments. This encompasses the entire spectrum of necessary treatments that aid employees in achieving full recovery or reaching their “maximum medical improvement” if complete recovery proves unattainable. Surgery, when deemed essential, falls within the ambit of covered treatments.
How Long Does Workers’ Comp Have to Approve Surgery?
Consider a scenario where you sustain a job-related injury, and your doctor recommends surgery. In such instances, ensuring the coverage of your surgery costs through workers’ comp involves understanding your rights and the approval process.
While employers and their insurance companies generally lack the discretion to arbitrarily deny coverage for necessary treatment when an employee is eligible for workers’ comp, denials for surgery are not uncommon. Given the substantial costs associated with surgical procedures, companies often prioritize their financial interests. It’s crucial, however, not to let this deter you from pursuing the treatment you need, even if you could potentially afford the surgery independently.
Understanding When Approval for Surgery Is (and Isn’t) Required
In practical terms, your doctor might seek pre-approval for a procedure to ensure compensation, considering the uncertainty surrounding payment. However, this presents a dilemma – you want approval for surgery but are wary of providing your employer or its insurance company the option to refuse.
In cases where preauthorization is mandated, navigating this landscape becomes intricate. Balancing the need for approval with the desire to avoid potential denial requires careful consideration.
If you find yourself in a situation where workers’ comp needs to approve surgery, your doctor’s office should initiate the request, prompting a timely response from your employer or its insurance company. However, this doesn’t always transpire seamlessly.
Before covering surgery costs, your employer or its insurance company may insist on an “independent medical exam,” which, despite its name, is often far from impartial. This exam, conducted by a doctor affiliated with insurance companies, poses risks, as the doctor may opine against the necessity of surgery, potentially leaving you without coverage for the needed procedure.
To navigate these intricacies, having an advocate on your side becomes imperative. Hiring a lawyer can facilitate dealings with your employer and its insurance company, providing guidance on the necessity of an independent medical exam and advising on the best course of action during the examination to enhance the likelihood of approval.
What Happens if Workers’ Comp Won’t Approve Your Surgery?
If, for any reason, workers’ comp refuses approval for your surgery, you retain legal rights. Challenging the denial within the stipulated timeframe becomes crucial.
The specific steps and timelines for challenging a denial depend on your location, as workers’ compensation laws vary by state, each with its unique appeals processes. Prompt consultation with a local lawyer is essential to understand the actions required to seek coverage for your procedure.
How Long Should It Take for Workers’ Comp to Approve Surgery?
In the quest for initial approval, the duration for workers’ comp to approve surgery lacks specific deadlines. Employers and their insurance companies generally have a duty to act reasonably and avoid bad-faith practices. The time window for approval may vary based on the urgency of the situation – emergency surgeries might necessitate swift approval, while non-life-threatening cases may involve a more extended timeframe.
Returning to the original query of “How long does workers’ comp have to approve surgery?” yields a frustrating answer: it depends. Seeking assistance from an experienced local attorney is advisable to expedite the approval process for your surgery if needed.
