Workers’ Compensation is supposed to cover all medical care needed to treat your work-related injury. This can include surgeries, but insurance companies might try to refuse coverage, since surgeries are expensive.
You should be able to get knee replacement surgery if you need it because of your work-related injury. Workers’ Comp should cover every dollar of the surgery, pain medication, and physical therapy. However, insurance companies might try to refuse coverage, and a utilization review might be needed. With surgeries, you can also get a second opinion and potentially choose your own doctor, depending on when the surgery happens.
For help with your injury case, call Cardamone Law’s Certified Pennsylvania Workers’ Compensation Lawyers at (267) 651-7945 today.
How Do You Get Knee Surgery Covered Under Workers’ Compensation?
Workers’ Compensation is supposed to cover all medical care needed to treat a work-related injury, requiring the following steps to get coverage:
File Your Claim
You need to file your claim first before you can get medical care covered. Claims are filed by notifying your employer of your injury within 21 days. Then, they either reject or accept your claim.
If they reject it, you can file a Claim Petition with the state within 3 years of your injury. This should be done with help from a Pennsylvania Workers’ Comp lawyer.
Doctor Recommends Surgery
While undergoing medical care for your injury, your doctor will be the one to recommend the surgery. If you need something like a total knee replacement, this will usually be recommended after consultation with multiple doctors, including orthopedists and orthopedic surgeons.
Getting Second Opinion
If surgery is recommended, you can request a second opinion, and Workers’ Comp should cover it. This allows you to consult with a second doctor about whether the surgery is really necessary, whether other courses of treatment are available, etc., before you commit to surgery.
No Preapproval Needed
Workers’ Comp doesn’t work the same way as health insurance, where your insurance company might want prior notice of the intended course of care so they can preapprove surgeries or treatments.
Instead, once your treating physician says it is reasonable and necessary care, they can provide the care and bill Workers’ Comp directly. If Workers’ Comp refuses to pay for it later, we can deal with that when it comes up.
Get the Surgery
You then get the surgeries you need. This can cover things like total knee replacement surgeries, which are actually a surprisingly common work-related surgery.
Follow-Up Care
Knee replacement also needs a lot of follow-up care for your proper recovery, including physical therapy and rehabilitation. This often requires medication and painkillers, which should be covered alongside rehab costs.
Possible Challenges and Issues
Any time surgery is recommended as a course of treatment for your injuries, there are a few potential problems that could arise. This is especially true when it is an expensive procedure like a total knee replacement.
Insurance Won’t Accept Claim
If the Workers’ Comp insurance carrier thinks you will need a knee replacement for your injury, they may challenge the initial claim. If they can avoid accepting your claim, then they can avoid paying for the knee replacement costs.
This might mean we have to take the case to a Claim Petition and go before a Workers’ Comp Judge just to get your claim accepted in the first place.
Refusing Coverage for Surgery
If the claim is accepted, the insurance company might then try to fight coverage for the knee replacement surgery. Their doctors might say it is unnecessary or that you can do physical therapy instead, and that a knee replacement isn’t indicated until all of that is tried and doesn’t work out.
In many cases, this isn’t the sound treatment path, and medical evidence can prove as much.
Utilization Reviews
Along with claiming that knee replacement surgery isn’t needed, the employer will usually have to challenge that formally through what’s called a “Utilization Review” (UR). This means taking the issue of whether or not the knee replacement is necessary and reasonable before a Workers’ Comp Judge.
Both sides present medical reports and doctors’ opinions about the treatment needs and reasonableness, and the court decides whether the insurance company has to cover it or not.
Surgical Complications
If there are surgical complications, you may need additional care afterward. This adds to the expense, but you should not have to pay for it as long as you are properly following through with care, performing rehabilitation, etc.
FAQs for Knee Replacement Surgeries Under Workers’ Comp
Do You Need to Get Surgery if the Doctors Say So?
If you are on Workers’ Comp and getting your medical care paid for that way, then you have to follow your treating physician’s treatment plan. This means that if they say you need surgery – and your second opinion doctor doesn’t deny that – you need to go through with the surgery or risk losing coverage.
You can refuse surgery if you have serious objections, but you may not be able to continue getting your care covered if you do.
Can You Pick Your Surgeon?
If you get surgery within the first 90 days of care, you have to use doctors from a list of “panel doctors” your employer chose. You can choose a doctor to give you a second opinion, but a listed doctor still has to be the one to perform the surgery.
There is an exception: you can choose specialists from outside the list if the list doesn’t have the kind of specialists you need. Orthopedic surgeons may be listed, since these kinds of injuries are common for some jobs. If not, you may choose your own surgeon in most cases.
You can also choose your own surgeon if the surgery happens after the first 90 days of care.
Call Our Workers’ Compensation Attorneys in Pennsylvania for Help Today
For your free case evaluation, call Cardamone Law’s Philadelphia Workers’ Comp lawyers at (267) 651-7945.
