Severe hip injuries cause excruciating pain. They affect your ability to do just about anything including standing, sitting, and walking.
The pain from these injuries can make it difficult to get comfortable and enjoy any sort of activity. Many people cannot work because of their limitations from serious hip injuries.
In recent years, hip replacement has become one 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 performed by an authorized doctor and you need it because of your injury.
Unfortunately, there is a lot of confusion about this. I have encountered situations where doctors will not ask for approval of a hip replacement surgery because they believe the insurance company will not cover it. It is important for you to understand that your hip replacement might should be paid by workers compensation if you suffered an injury to your hip at work.
Suppose you were not having any problems with your hip at all. Then, you fall at work and suffer a serious injury to your hip. Now, your doctor recommends a hip replacement. Is it covered?
Probably yes. If the sole need for the hip replacement was the injury you suffered at work, then the hip replacement should almost certainly be covered in that situation.
Unfortunately, many people find themselves dealing with hip injuries where the answer to the question is less straightforward. These situations often involve a hip injury at work where the insurance company argues that you had a preexisting condition in your hip. The insurance company tries to argue that it is the preexisting condition that caused the need for surgery.
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. Avoiding paying the cost of the hip replacement surgery will save the insurance company money.
But, the workers compensation insurance company may have to pay for the hip replacement even if you had problems with your hip beforehand. 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 pays for hip replacement. What happens after you get that surgery done?
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 than you did beforehand.
Of course, sometimes surgeries do not go as well as you hope. You may still have significant problems even after you recover from the surgery. 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
There are limits under Georgia’s workers compensation law on how long the workers compensation insurance company has to pay for medical treatment for your injury. In most cases, the insurance company’s responsibility for medical treatment ends 400 weeks from your injury.
But, there are exceptions to these limits on medical treatment. One exception applies if you qualify for a catastrophic designation. Even if you do not qualify for a catastrophic designation, there are three other exceptions that could apply to medical treatment and testing more than 400 weeks after your injury.
One of these exceptions specifically addresses hip replacements and other treatment that involve prosthetic devices. It is important to understand that the treatment involving the prosthetic device has to originally happen within 400 weeks of the original injury for the exception to apply.
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 discussed 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 they recover from their surgery and reach maximum medical improvement. 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.
If you are able to return to work but have reduced earning because you are limited to restricted work, you may should receive temporary partial disability benefits. These are wage loss benefits that compensate you for the situation of when you are able to work but earn less because of your injury.
Also, temporary partial disability end up getting paid because a document known as a Form WC-104 goes into effect a year or more after the doctor releases you to return to light duty work. The WC-104 going into effect involves a conversion of your benefits from temporary total disability to temporary partial disability. This conversion often results in a decrease in the amount of your weekly benefit. If the insurance company does not strictly follow the rules on a Form WC-104, an attorney representing you in your workers compensation case may be able to invalidate this conversion.
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.
The AMA Guides have different chapters of the book devoted to different systems of the body. Hip injuries are primarily covered in Chapter 17 which is entitled “The Lower Extremities”.
Doctors rate total hip replacements using Table 17-33 and Table 17-34 of the AMA Guides. The doctors use Table 17-34 to determine what type of recovery you had following the hip replacement surgery. This table take into account different factors to calculate a score. This score determines whether you had a good, fair, or poor outcome from the surgery.
This score from Table 17-34 is then used to determine your permanent partial disability rating in Table 17-33:
- “Good” results receive a permanent partial disability rating of 37% to the lower extremity which equates to 15% to the body as a whole
- “Fair” results receive a permanent partial disability rating of 50% to the lower extremity which equates to 20% to the body as a whole
- “Poor” results receive a permanent partial disability rating of 75% to the lower extremity which equates to 30% to the body as a whole
When you receive a rating, you should check to make sure it looks like you were rated correctly. You should receive a document called a Form WC-2 when the insurance company starts paying the PPD benefits. This document should state the amount of the PPD rating on it and a copy of the rating from the doctor should be attached.
Even when you are rated correctly, the insurance company may try to pay you a lower amount than you should get paid. They do this by paying the body as a whole rating instead of paying the lower extremity rating. 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 to qualify for that catastrophic designation.
Whether you can prove this will likely depend on how severe your work restrictions are. Other factors, such as your education and work experience, will 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 in making that decision.
Also, some people like to get a second opinion before making a decision about surgery. Under Georgia’s workers compensation laws, there are ways to get medical second opinions.
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. A free consultation is one of the best ways to get answers to your workers compensation legal questions.