Workers’ Compensation and Surgery

An experienced lawyer can help you navigate the claims process

Every year, workers in San Diego are injured in workplace accidents. In some cases, their injuries may require surgery. The workers’ compensation system in California is designed to cover the costs of all necessary medical treatment for injured workers. But insurance companies may still deny coverage for surgery.

That’s why it’s important to have an experienced San Diego workers’ compensation attorney on your side. At Robert A. McLaughlin, APC, we understand the impact that an injury can have on workers and their families. We fight to help them get the surgery and other medical treatment they need so they can move forward with their lives.

What types of work-related injuries require surgery?

There is a wide range of work-related injuries in California that may require surgery. While any injury could potentially require surgery if it’s severe enough, here are some common types of injuries that might require surgical intervention:

Broken bones: Severe fractures, such as compound fractures or fractures that involve multiple bones or joints, may require surgical repair with the use of pins, plates, screws, or other hardware.
Joint injuries: Injuries to joints such as the knee, shoulder, hip, and ankle, including torn ligaments (e.g., ACL tears), may require surgical procedures such as arthroscopy or joint replacement.
Spinal cord injuries: Severe spinal injuries, such as herniated discs, fractures, or spinal cord compression, may require surgery to alleviate pressure on the nerves or stabilize the spine.
Carpal tunnel syndrome: In some cases, advanced or severe carpal tunnel syndrome that doesn’t respond to conservative treatments might require surgical release of the carpal tunnel.
Tendon and ligament injuries: Severe tendon or ligament injuries, such as complete tears or avulsions, might require surgical repair to restore function and stability.
Burns and trauma: Severe burns or traumatic injuries, especially those involving damage to multiple layers of tissue, may require surgical treatment, including skin grafts.
Amputations: Crush injuries or accidents involving heavy machinery might result in amputations that require surgical intervention.

Only a doctor can determine whether your work injury requires surgery. Following a surgical procedure, you will also be put on a post-operative care plan. This may include medication, wound care, physical therapy, and multiple follow-up visits to monitor your progress.

Does workers’ compensation pay for surgery in California?

Workers’ compensation generally covers medical treatment, including surgery, that is necessary due to a work-related injury or illness. This includes all costs associated with the surgery, such as surgeon fees, hospitalization, anesthesia, and post-operative care.

But there are several factors to consider. These include:

The surgeon: In California, employers often have a medical provider network (MPN) or healthcare organization (HCO) that includes approved doctors and specialists. If you are seeking surgery, you should select a doctor from this network. The authorized doctor will evaluate your condition and recommend the appropriate course of action.
Authorization: Before undergoing surgery, it’s important to follow the proper procedures to obtain authorization from your employer’s workers’ compensation insurance carrier. Your doctor will need to submit a treatment plan and obtain approval from the insurance company to proceed with the surgery.
Coverage limits: Workers’ compensation generally covers the cost of all necessary medical treatments, including surgery. However, it’s important to note that medical treatments must be authorized by your employer’s workers’ compensation insurance carrier.

It’s crucial to follow proper procedures and documentation when seeking medical treatment and surgery through workers’ compensation. If you’re not sure about the coverage for a specific medical procedure or have questions about the process, talk to an experienced workers’ compensation attorney.

How long will it take to approve my surgery?

There is no average timeframe, and the length of the approval process can vary based on several factors. These include the complexity of your surgery, whether there is a dispute over the necessity of the procedure, and the responsiveness of the insurance company. Surgeries that are not considered urgent may take longer to approve.

All requests to approve surgery must go through the same process. You will need to undergo a medical evaluation, and your doctor must seek authorization from the insurance company. The request will undergo a review process. The insurance company may contact your doctor to ask questions, and in some cases, additional documentation may be sought.

Why was my request for surgery denied?

There can be several reasons given when a request to cover the costs of surgery are denied. Some examples:

The insurance company determined the surgery is not medically necessary.
There is a dispute over whether your injury was work-related.
There was insufficient documentation provided to approve the surgery.
It was determined that your injury was due to a pre-existing condition.
Your surgery would be performed by a non-authorized provider.

If coverage of your surgery is denied, you can appeal the decision to the Administrative Director of the Division of Workers’ Compensation (referred to as “Independent Medical Review”).

How can a workers’ compensation lawyer help me if I need surgery?

An experienced workers’ compensation attorney can work with your doctors to build a strong case for why surgery is necessary. If your request for surgery is denied, your lawyer can help you navigate the appeals process and negotiate a resolution with the insurance company to ensure you get the treatment you need.

When a doctor recommends surgery for your work-related injury, getting approval from the insurance company should be simple process. But the reality is that employers and their insurance carriers often dispute claims to try to keep their costs down. We think you deserve better.

Our experienced attorney can guide you through the claims process every step of the way and will fight for the best possible outcome. Learn more about how we can help and get answers to your questions. Contact us to schedule a free case review.