After a serious injury, your doctor may say that you need surgery to have the best recovery. Many people get frustrated because they run into a problem at this point when the workers compensation insurance company will not approve the surgery.
If you find yourself in this situation, you probably have many questions:
- Does workers compensation require the insurance company to pay for surgery?
- What can you do if the insurance company does not meet its obligation of paying for surgery?
I talk to many people who find themselves in this situation. This article will attempt to address some of your questions about getting the insurance company to authorize workers compensation surgery.
The first question you may have is whether Georgia’s workers compensation laws require the insurance company to pay for surgery. Generally, the law in Georgia requires the workers compensation insurance company to pays for the medical treatment and testing that you need as a result of your injury at work.
Surgery is often a type of medical treatment that you need because of your injury at work. Many injured workers need surgery to repair herniated disc, torn ligaments, or broken bones.
There are some special rules about workers compensation medical treatment. For example, you cannot just have surgery with any doctor you want. The doctor performing treatment has to be an authorized physician.
If I am seeing a doctor, why does the insurance company not just approve my surgery?
If you have had an injury at work, there is a good chance the workers compensation insurance company has caused you some frustration. If you are at the point where your doctor is recommending surgery, then you may have waited several months going through nonsurgical treatment.
Now, your doctor is saying well you need surgery in order to have a full recovery from your injury. So, you may be a little bit frustrated but also a little bit hopeful that you’re going to get that surgery done, recover from it, and then be able to move on with your life. Unfortunately, just because your doctor recommends surgery does not mean that that surgery is going to be approved by the insurance company.
Insurance companies often delay or deny approval of workers’ compensation surgery. They do this in a few different ways.
One is just by not answering the doctor’s office when they ask for approval. So they do not provide an answer one way or another. Since your doctor does not want to proceed with surgery until they get approval, this delays your surgery.
A second way the insurance company delays treatment is by saying that you need a second opinion or that they need more information before they can approve the surgery.
A third way the insurance company delays is just by denying the surgery completely. They may tell the doctor they are not going to approve it or they may file a form called a WC-3 controvert denying that surgery.
So what can you do if your surgery is being delayed or denied?
The first thing you can do is reach out to the insurance company. You could speak with the adjuster or case manager and ask that they approve the surgery.
If this works, great. You can move forward and have the surgery.
A second option that’s available if this does not work is to use one of the forms that is published by the Georgia State Board of Workers’ Compensation to try to make medical treatment get approved faster.
One of these forms is called a WC-205. That is a form that will actually be used by your doctor’s office to request approval for the surgery.
Your doctor’s office can complete and submit the Form WC-205 to the adjuster. The adjuster has a certain amount of time to respond either approving the surgery or denying it. If the adjuster does not give any answer at all within the time allowed, then the surgery should be automatically approved.
A second form that can be used by you or your attorney is called a Form WC-PMT. The intent of this form is to allow you to set up a conference call with a workers’ compensation Administrative Law Judge.
When the Form WC-PMT is completed and submitted to the insurance company, the insurance company should either file a response approving the requested medical treatment or denying the requested medical treatment. If they do not do anything, then the conference call with the judge will take place.
What can you do if these tactics to get your surgery approved do not work?
If you cannot get your surgery approved, you could also try other ways of getting your case in front of a judge. You could file a Form WC-14 to request a hearing in front of a workers compensation judge. You could also file a motion to try to get treatment approved.
At a hearing, you or your attorney can try to prove that you should have the surgery that has been recommended as a result of your injury at work. I would certainly recommend that if you were going to go to court about your case that you talk to an attorney and hopefully hire an attorney to represent you.
Workers compensation court has special rules. If you do not understand these rules, there is a good chance that you could lose your case.