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Surgery In A Workers’ Compensation Case

  • Owner
  • 07/31/2023

It’s bad enough if you strain your neck, back, or knee on the job and cannot work for a couple, three months. But if you need surgery because of your injury – that’s a whole different ballgame.

Pennsylvania workers’ compensation law provides that somebody who injures themself at work and is disabled from their job is entitled to money for lost wages and payment of medical bills. That doesn’t necessarily mean the insurance company will do the right thing and accept your claim if you injure yourself at work. It may deny your claim for any number of reasons (for example, your injury didn’t occur in the course of your employment or was caused by a pre-existing condition), or may agree to pay your medical bills, but deny that you are disabled and not pay you wage loss benefits.

Let’s run through a few scenarios, and for some, we’ll throw surgery into the mix. If you sustain a strain injury that requires you to undergo physical therapy as well as take medication for two months, then you return to your job, and the insurance company picks up your claim and pays you money for lost wages as well as your medical bills, you should consider yourself very fortunate.

Things are usually not that simple, though. We’re going to change things up and say that your injury is more serious than a sprain – the MRI of your low back shows a herniated disc at two levels. Physical therapy doesn’t help much so you try a series of epidural steroid injections, and they only give you partial, short-term relief. You are referred to an orthopedic surgeon, who recommends surgery given that you have tried conservative treatment, but it has failed to resolve your back pain. The big questions are: If you want to get the surgery, will you be able to, and if so, will the workers’ comp. insurance company for your employer pay for it? It depends on several factors.

If your claim has been denied by the insurance company, you can bet that they won’t voluntarily pay for your surgery. You will probably have hired a lawyer to file a petition for you, and if the Workers’ Compensation Judge rules in your favor, then the insurance company will have to pay for the surgery. But that process is lengthy. In the meantime, if your pain is so severe that you want to go ahead with surgery, you still may be able to get it if you have other health insurance (through your employer, the state, or you’re on your spouse’s insurance plan), and that insurance company agrees to pay for your surgery. This may require proof that you have filed a Pennsylvania workers’ compensation claim, which has been denied. Under those circumstances, the other insurance company may seek to be reimbursed by the workers’ comp. insurance company if it’s later determined by the Judge that the surgery was related to your work injury.

But if you don’t have backup health insurance while your Pennsylvania workers’ compensation claim is being denied, we hate to say it, you’re probably going to have to hold off on the surgery. Unless a surgery is considered an emergency, the surgeon and the hospital where the surgery would be performed are not likely to proceed with the surgery without insurance. And of course, unless you have socked away a lot of money, you’re not going to be able to pay for the surgery yourself. Very few people have the means to pay for a surgery out of their own pocket.

Let’s turn to another issue: How does the surgery issue factor in when there is a possibility there will be a settlement of your Pennsylvania workers’ compensation claim? During your case, a Workers’ Compensation Judge may hold a mediation (also called a settlement conference) that you, your lawyer, and the insurance company’s lawyer will attend. Since the start of the pandemic, these have been held virtually. The Judge will speak to you and your lawyer privately, then the insurance company lawyer privately, and go back and forth in an effort to facilitate a settlement of your claim.

It’s important for you to understand that when an insurance company enters into a settlement of a Pennsylvania workers’ compensationclaim, it almost always requires that the injured worker sign off on all claims. In other words, once a settlement is approved, the insurance company will not have to pay you any more money or any of your medical bills – they are off the hook forever. Your claim cannot be reopened. Therefore, settlement, while always a serious consideration, becomes especially important if your doctor has recommended surgery for you. The insurance company may be willing to offer you more money if surgery is on the table because it realizes that if your claim is not settled, and you undergo the surgery, it may have to foot a hefty bill. Needless to say, the more significant the surgery, the more money an insurance company may agree to offer you to settle your claim.

But beware – if you settle your claim and then have to undergo surgery, you will have no choice but to submit this through another insurance company, assuming you have that option. And after surgery, undoubtedly you will have to participate in physical therapy, see your surgeon for follow-up visits, and take medication. Even if you have backup insurance with, say, Blue Cross, you’ll likely have to incur significant co-pays for your surgery and follow-up care. If your surgery is covered by workers’ comp, however, there would be no co-pays – you would pay nothing out-of-pocket.

Here’s the bottom line: If you have been hurt at work, whether it is a minor injury or you are a candidate for surgery, it is critical that you have a top-notch PA workers’ compensation lawyer to represent you to give you advice throughout your claim, and get you the maximum benefits to which you are entitled. At Pearson Koutcher Law, workers’ comp. is all we do, every day. We have represented countless clients who have injured themselves at work and have not needed surgery and countless clients who have needed surgery. Either way, you are in great hands with an experienced, knowledgeable Pennsylvania workers’ compensation lawyer from Pearson Koutcher. Please call us today for a free, comprehensive consultation.