Under New York law, employers are required to provide workers’ compensation benefits for their employees. If you are hurt at work or develop an occupational illness, these benefits will pay the associated medical bills and give you cash to cover your lost wages.
The workers’ comp system is no-fault, which means that you don’t have to prove that your employer did something wrong in order to recover. Even so, the insurer may still deny your claim entirely – or deny a specific request, such as for surgery. If workers’ comp won’t approve surgery, then you may need to dispute the denial with the Workers’ Compensation Board.
Surgery may be medically necessary for you to fully recover from your workplace injury. If your employer or their workers’ comp carrier denies your surgery, an experienced workers’ compensation attorney can help.
Workers’ Comp Medical Benefits Explained
In New York, the workers’ compensation insurance company must pay for all reasonable and necessary medical treatment related to a work injury or illness. Other than in emergencies, the healthcare provider who treats you must be authorized by the New York Workers’ Compensation Board.
Medical benefits include:
- Medically necessary medications
- Assistive devices
This care will be paid for directly through your employer’s workers’ comp insurance.
The insurer may dispute medical services, including surgery. A denial may be based on a number of reasons, including:
- Not a work-related injury or illness (causation): the insurance company may argue that your injuries were not caused by a workplace accident.
- Likelihood of effectiveness: if the surgery is not reasonably likely to cure your condition or allow you to return to employment, then the insurer may deny it.
- Unauthorized provider: if the surgeon is not approved by the Board, then the insurer may deny payment.
A denial often occurs after the insurance company or employer receives a request for written authorization (form C4AUTH). A treating physician must request authorization for any special services that cost over $1,000, or for any service that requires pre-authorization under the Medical Treatment Guidelines. If a recommended surgery does not fall within these guidelines, your doctor will also have to request authorization.
Once the insurance company receives the C4AUTH, it has 30 days to either approve or deny a surgery. If the insurer denies the surgery, then they must also provide a written explanation of the reason for the denial. Under Board Rule 300.23(d), the insurer must file C-8.1 Part A within 5 days after a denial and attach a medical report on the basis for its denial. If the insurance carrier fails to do this, then their denial will be considered defective.
How to Fight a Workers’ Compensation Denial
If any part of your workers’ compensation claim is denied – including a request for surgery – then you may be able to file a dispute with the Workers’ Compensation Board. A seasoned workers’ comp attorney can help you with this process.
Before a dispute is filed, however, you may choose to talk to your treating doctor about the situation. Your physician is in the best possible position to dispute the insurance company’s claim. For example, if the insurer denies surgery on the basis that it won’t be effective, your doctor can provide information about the likelihood of success, typical outcomes for this type of surgery, and other options that have been (or could be) pursued.
If workers’ comp won’t pay for surgery even after your doctor files an appeal, then you may dispute the denial with the Board. At this point, either your own workers’ compensation attorney or the insurance company may request that you get a second opinion, or that you go to an independent medical evaluation (IME) to determine whether the surgery is medically necessary. Workers’ comp insurers often request an IME when they disagree with your treating doctor about the course of your medical care – particularly when the recommendation is for an expansive treatment like surgery.
During an independent medical exam, a doctor will review your medical records, examine you and ask questions about your injury and symptoms. Keep in mind that this is not like a typical doctor’s appointment. During the IME, the medical provider will be seeking information to use in a report about your condition – which can ultimately help or hurt your claim. In this type of examination, anything that you say and do may ultimately make it into a report that is provided to all parties and the Workers’ Compensation Board.
After the IME report is issued, the insurance company may agree to approve the surgery as part of your workers’ compensation benefits. However, if there is still a disagreement as to whether surgery is necessary, then your lawyer may file a workers’ comp claim to ask the Board to resolve the matter.
Under New York workers’ compensation law, this type of dispute may be resolved in a number of ways, including:
- An administrative decision by the Board reviewed and approved by a Workers’ Compensation Law Judge (WCLJ);
- Conciliation, which involves an attorney for the Board attempting to get the parties to agree to a resolution;
- An order of the chair, approving the surgery if the employer or insurance carrier fails to approve or deny a request for medical services in a timely manner; or
- A hearing before a WCLJ
Throughout the process, your workers’ comp attorney will advocate for your right to necessary medical treatment, and work with you to get the surgery approved.
Workers’ Comp Denied My Surgery. Can My Health Insurance Pay for It?
If workers’ compensation refuses to pay for your surgery, you may be tempted to have these medical expenses covered by your own health insurance. In some situations, your own insurance may cover medical treatment – such as for an injury or illness that is not work-related. However, if you need surgery for a workplace injury, then your insurance won’t pay for it.
These situations are complicated, and any decision that you make can affect your right to workers’ comp benefits. As such, your best option is to schedule a free consultation with a workers’ comp law firm, where you can get advice on how to proceed.
Can Workers’ Comp Insurance Deny Surgery?
Yes. If the insurance company believes that the surgery is not reasonable and necessary, if they believe that your injury is not work-related, or if the treating doctor is not authorized, then they may deny surgery.
In this situation, you may seek a second opinion or may undergo an independent medical exam. If the insurance company still denies your request for surgery, then your workers’ comp lawyer may file a dispute with the Workers’ Compensation Board.
Help for Injured Workers
Getting hurt at work can be incredibly scary. In addition to medical bills, you also may be out of work and suffering financially. Workers’ comp is supposed to cover these expenses – but if they deny all or part of your claim, you may not know what to do next.
Attorney Paul Giannetti has substantial experience helping injured workers get the full benefits that they are entitled to under the law. If workers’ comp denied your surgery, he will fight for your rights. To learn more or to schedule a free consultation with an Albany workers’ compensation attorney, reach out today at 518-243-8011 or fill out our online contact form.