What if Workers’ Comp Denied Your Surgery?

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When you’re hurt at work, you should receive workers’ compensation benefits. These benefits should include necessary surgery.

It should be as simple as reporting your workplace injury and getting surgery if you need it. Unfortunately, many injured workers are left wondering what to do if workers’ comp denies their surgery. Fortunately, there are things you can do.

If you need to know what you can do if workers’ comp denies your surgery, our Greenville workers’ compensation lawyer can help.

What Can You Do If Workers’ Comp Denies Your Surgery?

If workers’ comp denies your surgery, you can have a hearing in front of a workers’ compensation commissioner. The commissioner reviews the evidence and decides whether to approve the surgery. In addition, you can ask for another doctor or negotiate a settlement.

7 Things You Can Do if Workers’ Comp Denies Your Surgery

Here are seven things you can do if workers’ comp denies your surgery:

    1. Ask for a hearing

You can take your case to a hearing. There, a neutral hearing officer for the South Carolina Workers’ Compensation Commission will review all the evidence and decide whether the surgery is a covered benefit. This option doesn’t require any cooperation from the workers’ compensation insurance provider. If you file for a hearing, you can have one.

To request your hearing, you must file Form 50 – Employee’s Request for Hearing. The form requires the basic case information. In box 7(b), you’ll state that you’re seeking additional medical examination and treatment, and then you’ll give details. In line 13b, you’ll state that you are requesting a hearing. There is a $50 hearing fee.

To give your hearing the best chance for success, you’ll need to present evidence. You may present your medical records, statements from the treating physician, your own medical experts, and other information to support your case. This testimony must be prepared and presented effectively. Form 58 allows you to provide a pre-hearing brief to explain the issues in a succinct manner.

If the court agrees with you, they’ll order your surgery as part of your medical benefits. If you’re unhappy with the decision, you can appeal to the full commission and then to the courts.

    2. Ask for another doctor

If your workers’ comp surgery has been denied, you can ask your care provider to allow you to go to another doctor. Ask your insurance adjuster if they’ll allow you to get a second opinion or go to another doctor for treatment. They may allow it. Remember that you must receive care from someone who is approved by the insurer, so you can’t go to any doctor of your choice.

Getting a second opinion about your surgery is an issue that you can raise in a hearing. Use Form 50 to request your hearing. You can have a lawyer represent you.

    3. Negotiate a settlement

Even if you and the workers’ comp insurer disagree about whether you should receive the surgery, you may resolve your case through a negotiated settlement. When surgery is contested, a settlement may be for a lump sum without covering the surgery. Then, the injured worker may use those funds to have the surgery on their own.

There are many ways to settle a case. Sometimes, future medical care is still possible after a settlement for lost wages. However, if you need surgery that has been denied, that may not be the right settlement for you. It may be beneficial to receive a lump sum payment with an agreement that future medical care must be sought on your own.

If you are considering any kind of settlement, it’s critical to fully understand the terms. Settlements vary significantly in what they cover. Lawyer Robert “Bobby” Jones can help you understand the settlement and negotiate favorable terms.

    4. Request mediation

You can mediate the issue of your workers’ compensation surgery. Mediation requires a representative from the insurance company to discuss the case in a guided meeting with a trained mediator. On Form 50, there is a place to request mediation. You can also ask the insurer to mediate the case without a court order.

Mediation is helpful in many cases, but it’s not always appropriate. Lawyer Bobby Jones can help you determine whether mediation is a good option. He can represent you in mediation proceedings and in all aspects of your case.

    5. Ask them to reconsider

When workers’ comp denies a surgical procedure, you can ask them to reconsider. Ask what they are questioning – whether the surgery is medically necessary or whether the medical condition is the result of a workplace injury. It may be possible to discuss the issue with the care provider and ask them to approve the surgery.

    6. File a personal injury claim

Sometimes, a person who has been injured on the job qualifies to file a personal injury claim. A personal injury claim is different in several ways. You must show the liability of a third party, and that your medical bills are the result of your injuries. Even if the surgery has been denied through workers’ compensation, you may be able to prove your personal injury claim and receive compensation that pays for the surgery.

The decision to file a personal injury claim is complex. It is only available if there is a third party, other than your employer, who is responsible for the accident and your injuries. If you qualify to bring a third-party claim, in addition to claiming surgery expenses, you may claim pain and suffering and other non-economic damages.

    7. Use your own health insurance or resources

When workers’ comp denies your surgery, you may use your own health insurance and private resources to have your surgery. Of course, this isn’t fair when you’re hurt on the job, so please talk to lawyer Bobby Jones about your case.

Contact Our Firm About Denied Surgery Compensation

Has workers’ comp denied your surgery? Lawyer Robert “Bobby” Jones of Bobby Jones Law can give you a personalized consultation about what to do.

Call 864-362-2640 or message us for a free consultation about your case.

The team at Bobby Jones Law LLC works tirelessly for the injured in South Carolina. His achievements include:
  • More than $60 million collected for our clients
  • Multiple recoveries exceeding $1 million, including an eight-figure settlement
  • Recognized by Best Lawyers in America
  • Named among the “Best Law Firms” by U.S. News & World Report
  • Named to the Top 100 Trial Lawyers by The National Trial Lawyers
  • Named to Super Lawyers 2017–2024
  • Member of the Million Dollar Advocates Forum
  • Selected as Legal Elite of the Upstate 2021–2023
We’re humbled to be considered one of the top firms in the Upstate and invite you to learn what sets our award-winning legal services apart. Call or request a consultation online.
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