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Work Injuries and Surgery

  • Dave Brown, Esquire
  • 10/05/2020

If you hurt yourself at work, and it’s not a serious injury, you will probably be able to get treated adequately with medication, physical therapy, and maybe some injections. However, what happens if your injury is serious enough that you may require surgery — to your back, shoulder, knee, or another body part? Will workers’ comp. cover it?

Once you sustain an injury at work, the workers’ compensation insurance company for your employer will either accept your claim (pay you money for your lost wages, as well as your medical bills), deny your claim (not agree to pay you money or your medical bills), or accept only the medical part of your claim (pay your medical bills for the injury they have accepted, but not pay you money). If the insurance company denies your claim outright or denies the wage loss portion of your claim, you can file a Claim Petition with the Bureau of Workers’ Compensation; you should hire a lawyer If that becomes necessary.

If while you are treating for your injury, your doctor recommends that you undergo surgery, and you want to get it because you’re in a lot of pain and limited in your ability to function, whether the workers’ comp. insurance company will pay — in fact, whether you will even be able to get the surgery — depends on the status of your claim. If they have denied your claim, you can be sure that they will not pay for the surgery if you undergo it. The question under these circumstances is — do you have any other health insurance, through your employer, your spouse, or the state? If you do, that insurance company should pay for the surgery as long as they are provided with documentation that the workers’ comp. carrier has denied the claim. If your other insurance pays for the surgery, and the Workers’ Compensation Judge later finds the surgery is related to your injury at work, then the insurance company that paid may seek reimbursement from the workers’ comp. insurance company.

If your claim has been denied by workers’ comp., and you do not have other insurance, it will be difficult for you to have the surgery because the hospital is unlikely to allow the surgery to proceed. An exception is if you need emergency surgery. For example, suppose that you were at work and broke your leg when a large machine landed on you. If you were rushed to the hospital by ambulance, and the emergency room doctor determined that you needed surgery right away, the hospital will allow the surgery to be performed even if you don’t have any insurance because it’s an emergency.

If your workers’ comp. claim has been accepted, then the workers’ comp. insurance company should pay for your surgery. However, the workers’ comp. law in Pennsylvania does not require that the insurance company “pre-authorize” payment for the surgery. The hospital, though, should agree to allow the surgery to go forward on the basis that your workers’ comp. claim has been accepted. After you undergo the surgery, the bill will be submitted to the insurance company, which will have 30 days to make payment. If they don’t pay the bill within 30 days, the insurance company can be subjected to penalties under workers’ comp. law, requiring them to pay money over and above the bill for the surgery.

Whether workers’ comp. pays for the surgery may be dictated by the description of injury they provide on the document they issue accepting the claim. If they have accepted that you sustained a rotator cuff injury, and the surgery is to repair your rotator cuff, it is very likely that they will pay for the surgery without a fight. But if workers’ comp. accepted the claim as a minor injury, such as a low back sprain, and your doctor recommends surgery for a herniated disc, it is possible that workers’ comp, will decline to pay for the surgery, contending that although they accepted a back injury, they did not accept a herniated disc.

Another thing to keep in mind is the issue of whether your injury is serious enough to require surgery can affect your decision to settle your case. If your claim is denied and your case goes before a Workers’ Compensation Judge, in all likelihood the Judge will schedule mediation (a settlement conference) with another Judge
to see if a settlement can be reached. Most insurance companies insist that the injured worker sign off on the entire claim — both wage loss and medical. If you enter into one of these settlements, you will not be able to go back to the workers’ comp. insurance company for payment of medical bills in the future. If your injury is not too serious and no doctor has told you that you might need surgery, you should be more willing to enter into a full settlement. However, if a doctor has mentioned surgery — either that you need it as soon as possible or you may need it down the road should your condition not improve — it can be risky to sign off on a full settlement. If you do, and then six months later your doctor highly recommends surgery, you’re going to be in a predicament unless you have other insurance that you can put the surgery through.

Whether you sustain a minor injury which can be treated conservatively or a serious injury that requires surgery, Pearson Koutcher Law is the firm to go to for your workers’ comp. claim. Our team of
experienced, knowledgeable workers’ comp. lawyers will fight for you and make sure that your rights are protected throughout your case. So if you get hurt at work, don’t battle the insurance company yourself — call Pearson Koutcher Law for a free, comprehensive consultation, and let us go to bat for you.