Is Hip Replacement Covered By Workers Compensation?
Severe hip injuries cause excruciating pain. They affect your ability to do just about anything including standing, sitting, and working. In recent years, hip replacement has become a popular way to treat severe hip conditions.
When your worker compensation doctor recommends hip replacement, that recommendation can create a number of different issues. In this article, I will discuss a few of those issues including whether the workers compensation insurance company has to pay for hip replacement.
Does workers compensation cover hip replacement surgery?
Like many questions, the answer is, “It depends”. Hip replacement surgery is a treatment that is covered by workers compensation if it is reasonable and necessary treatment and you need it because of your injury.
Suppose you were not having any problems with your hip. Then, you fall at work and suffer an injury to your hip. Now, your doctor recommends a hip replacement. Is it covered?
Probably yes. In fact, the insurance company may have to pay for it even if you had problems with your hip beforehand.
However, workers compensation insurance companies love to argue that preexisting degenerative problems with your hips caused the need for hip replacement surgery. Many insurance companies deny your treating doctor’s request for authorization for the surgery on those grounds.
You need to know that insurance companies do not make the final decision on this. A workers compensation judge does. If your need for hip replacement was caused, aggravated, or accelerated by a work injury, you probably have a good chance of getting workers compensation to pay for the surgery.
Can I get additional medical treatment after hip replacement surgery?
Let’s assume that the workers compensation insurance company pay for hip replacement. What happens afterward?
You will have a recovery period after the surgery. Your doctor will probably order some physical therapy to help you heal and gain strength. Assuming everything goes well, you will hopefully feel much better.
Of course, sometimes surgeries do not go as well as expected. You may still have significant problems. The good thing is that the insurance company is not off the hook after the hip replacement surgery. They still have to pay for the medical treatment you need for your work injury.
This treatment could include some or all of the following:
- Revision of the hip replacement
- Other surgery
- Medications for pain
- Interventional pain management
What workers compensation benefits will I receive after hip replacement surgery?
The benefits you receive will depend on how your injury affects you. One benefit is continued medical treatment as I mentioned above.
Besides medical benefits, the two other main workers compensation benefits are:
- Wage loss benefits (temporary total or temporary partial disability); and
- Permanent partial disability benefits.
Will I continue to receive wage loss benefits?
Georgia law requires the insurance company to pay you temporary total disability benefits when your injury keeps you from working. Many people with hip replacements still have limits or restrictions on what they can do after surgery. If these limits or restrictions prevent you from working, the insurance company should continue paying temporary total disability benefits.
But, you need to remember that there are limits on how long you can draw these benefits. In most cases, you cannot draw the benefits more than 400 weeks after your work injury. Catastrophic designation, which I discuss below, is the main exception to this limit.
What about permanent partial disability (PPD) benefits?
You should receive a permanent partial disability rating after you recover from hip replacement surgery. Georgia workers compensation law currently requires doctors to use the Fifth Edition of the American Medical Association Guides to the Evaluation of Permanent Impairment for permanent partial disability ratings.
Doctors rate total hip replacements using Table 17-33 and Table 17-34. The doctors use Table 17-34 to determine what type of result you have. The amount of the rating depends on whether you get a good, fair, or poor result from the surgery.
- Good results – 37% to the lower extremity/15% to the body as a whole
- Fair results – 50% to the lower extremity/20% to the body as a whole
- Poor results – 75% to the lower extremity/30% to the body as a whole
When you receive a rating, check to make sure it looks like you were rated correctly. Even when you are rate correctly, the insurance company may try to pay you based on the rating to the body as whole. If this happens, you will receive substantially less in PPD benefits than you would under the lower extremity rating.
Can they do this? My reading of Georgia law is that you have a right to request whichever rating would pay you greater benefits. Consider this example:
- A 37% rating to the lower extremity pays 83.25 weeks of PPD benefits
- A 15% rating to the body as a whole pays 45 week of PPD benefits
If your weekly PPD rate is $500 per week, you would receive $41,625 using the lower extremity rating but only $22,500 using the body as a whole rating. That is a difference of almost $20,000!
Does hip replacement surgery qualify me for a catastrophic designation?
Again, it depends. If you want to know about catastrophic designation in greater detail, read this article I wrote that discusses the 6 different ways you can qualify for catastrophic designation.
Hip injuries will generally fall in the (g)(6) “catch all” category for catastrophic designation requests. This means that you will probably have to prove that you cannot do your prior work and any work available in substantial numbers in the national economy.
Whether you can prove this will likely depend on how severe your work restrictions are. Other factors, such as your education and work experience, play a factor as well.
Catastrophic designation has become even more important since the Georgia legislature changed the law in 2013 and limited medical treatment to 400 weeks. If you suffered your injury after June 30, 2013, your medical and income benefits will likely expire 400 weeks after your injury unless you qualify for a catastrophic designation.
What if I have other questions about hip replacement surgery?
First of all, let me say that some people have questions about whether they should have hip replacement surgery or not. That is a medical decision and you should consult with your doctor about it.
As a workers’ compensation attorney, I know a lot about workers compensation law but I am not trained to make medical decisions. Of course, if you have other questions about workers compensation, I am happy to try to answer them.
I find that a free consultation is usually the best way to do that. This article explains in more detail what a free consultation is and what you will learn. If you would like to set one up, just call our office at (770) 214-8885.
Jason Perkins is an attorney who specializes in representing injured workers. He regularly publishes videos and write blog articles about Georgia’s workers compensation system and issues that are important to injured workers and their families.
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