Needing surgery to treat an injury can be a scary and confusing experience. It is important to work with a lawyer and always get advice from doctors you trust about any serious medical interventions through Workers’ Comp, but that can be complicated when surgery is recommended.
If your Workers’ Comp doctor says you need surgery, it should be covered through Workers’ Comp. You are also typically entitled to a second opinion to review that determination, potentially allowing you to skip the surgery or undergo a different surgery/course of treatment than the Workers’ Comp doctor recommended. However, you usually cannot choose your own surgeon and must use a Workers’ Comp approved doctor if the surgery happens in the first 90 days of treatment. You may also not be able to say no to surgery without losing your Workers’ Comp benefits.
For help with your case, call the Certified Pennsylvania Workers’ Compensation Lawyers at Cardamone Law today at (267) 651-7945.
Does Workers’ Comp Cover Surgeries in Pennsylvania?
The short answer is yes, Workers’ Comp does pay for surgeries. However, there are special rules to make sure it is covered.
Claim Must Be Approved
Workers’ Compensation does not pay for claims it has not already accepted, settled, or been ordered by a Workers’ Comp Judge (WCJ) to pay. You have to get your claim approved before you can be sure treatment will be covered.
No Preapproval
While the claim has to be approved, there is no preapproval process for specific treatments under Workers’ Comp. This means you do not have to go to the insurance company first, get permission to get surgery, then get the care. Instead, the doctor approves it, and they send the bill to insurance.
If the insurance company later denies coverage for the surgical costs, our Bucks County, PA Workers’ Comp lawyers can take that issue before the WCJ in a process called a Utilization Review, which has the WCJ review doctors’ reports on whether the care is reasonable and medically necessary.
Listed Doctor Required in First 90 Days
If your treatment is happening within the first 90 days of your treatment, you usually have to use a doctor who comes from your employer’s approved “panel doctors.” This list usually includes at least one surgeon.
If the list does not include a surgeon in the appropriate specialty, you may be able to use a doctor of your choice.
Can I Choose My Doctor?
Workers’ Comp claims allow you to choose your own care providers if the care takes place after the first 90 days. Otherwise, this can be complex.
Panel Doctors
As mentioned, the panel doctors your employer chooses usually include at least one surgeon. If they can perform the surgery, and it is recommended within the first 90 days, then you may have to use that doctor.
If there are multiple panel doctors to choose between, the decision of which to use is typically yours to make.
Second Opinion
If you want a second opinion on invasive surgery, Workers’ Comp covers that. However, this is just a second opinion to determine the plan.
Your doctor you chose can review the panel doctor’s findings/recommendations and set a different course of treatment. This might include holding off on surgery, going with different therapies, or performing the surgery differently.
However, you cannot have this doctor perform the surgery instead if it is within the first 90 days of treatment.
Specialists
Sometimes you need surgery performed by a specialist. Often, panel doctor lists do not have an extensive list of specialists, and you may be able to choose a doctor from outside the list if you need an unlisted specialist.
Can You Refuse Surgery?
Medical care is extremely personal, especially surgery. Some people might be uncomfortable with the idea of surgery or receiving a particular surgery, especially if they have a second opinion saying other options should be used first.
Medical Standards
Your Workers’ Comp doctors must follow medical standards when recommending surgery. Surgical intervention is often seen as a last resort because it takes a bigger toll on the body. Physical therapy, injections, and other therapies might be attempted first before surgery is the proper course of action.
If your Workers’ Comp doctors are not following the standard of care, your second opinion doctor should be able to voice their concerns and help you see that proper medical care is administered.
Second Opinions Available
As mentioned, you can get a second opinion paid for when your Workers’ Comp doctor says you need surgery. You cannot get a different surgeon in many cases, but your chosen doctor’s course of treatment may be different.
If your doctor gives you a route to avoid surgery, you should be permitted to take it.
Refusal Can End Claim
If your second opinion doctor also recommends surgery, it might be the case that surgery is the best course of action. This might be difficult for you to accept, but if you refuse the surgery, it can be seen as noncompliance with your care.
Refusing recommended medical care is often grounds for your employer to terminate your Workers’ Comp claim or suspend benefits until you go through with the care.
FAQs for Workers’ Comp Surgeries in Pennsylvania
What Surgeries Are Common for Work Injuries?
Work injuries vary greatly, depending on your specific field and work tasks. However, Workers’ Comp often covers injuries like these:
- Hernia repair
- Tear repair (e.g., rotator cuff, ACL)
- Back and spine surgery (e.g., herniated disc repair, spinal fusion)
- Carpal tunnel release
- Joint replacement (e.g., knee, hip, shoulder).
Is Emergency Surgery Covered?
If you need to go straight to the hospital after an accident, it is possible you are going to get surgical care at the ER or trauma department. All emergency medical care like this is typically covered through Workers’ Comp.
What if They Won’t Approve Surgery for Your Work Injury?
If you think you need surgery, but your Workers’ Comp doctor refuses to do the surgery, you may be able to challenge this with medical evidence. We can often pay outside doctors for medical evaluations and reports that we can take before the WCJ to get care you need covered as part of your Workers’ Comp case.
If they refuse to cover a surgery you desperately need, you can potentially pay for the surgery on your own, then we can make a claim for compensation through Workers’ Comp or a lawsuit. Never spend money on your medical care without discussing it with your lawyer first; other options might be available.
Call Our Pennsylvania Workers’ Comp Lawyers Today
To get started with a free case review, call Cardamone Law’s Philadelphia Workers’ Comp lawyers at (267) 651-7945.
