You rightfully expect that the insurance company would pay for the medical treatment you need when you get hurt at work. You would also expect that your workers compensation doctor would be the one making decisions about what treatment you need.
Unfortunately, this often does not happen. One of the things that most people get frustrated with in Georgia’s workers compensation cases is the insurance company refusing to pay for a surgery their doctor recommended.
You may have to fight for the surgery your doctor recommends. Understanding why insurance companies do this can help you get the medical treatment you need.
Why would the insurance company refuse to approve my surgery?
Insurance companies have different reasons that they refuse to pay for surgery. But, the biggest reason they refuse to pay for surgery is probably believing that they save money.
Workers compensation insurance companies are businesses. Like most businesses, they are in business to make money.
A workers compensation insurance company makes money by receiving insurance premiums from employers. Just like you pay an insurance premium on your car or your house, employers pay premiums for workers compensation insurance. Our law firm, as a business, pays premium to an insurance company to provide workers compensation coverage for our employees.
In exchange for the payment of these premiums, the insurance company agrees to pay benefits when certain things happen. In the case of workers compensation, the insurance company is providing insurance for work-related injuries.
This means that the insurance company has to pay out money when you get hurt at work. This costs them money. If they pay out less to somebody when an injury occurs at work, then they make more money.
Surgery can be expensive. So, avoiding paying for a surgery can save an insurance company a lot of money.
Now, I am not saying that insurance companies are necessarily being unreasonable when they refuse to pay for surgery. What I am saying is many of them believe that refusing to authorize surgery and other expensive medical treatment saves them money.
Unfortunately, this means you may have to fight or have someone fight on your behalf to get the medical treatment you need.
Why will the workers compensation doctor not schedule my surgery without approval of the insurance company?
Georgia workers compensation law does not require doctors to have approval for surgery or any other medical treatment prior to performing it. But, it is very difficult if not impossible to get a workers compensation doctor to perform surgery without approval from the insurance company.
There is a good reason for this. Doctors and other medical providers want to get paid for the work that they do. If they perform treatment without approval from the insurance company, they take the risk that the insurance company might controvert the medical treatment they performed for some reason.
A controvert is just a fancy word for “deny”. If the insurance company controverts the treatment, then the doctor runs the risk of not getting paid for the work that they did.
What can I do to get my surgery approved by the workers compensation insurance company?
Ultimately, the reason the insurance company refuses to approve the surgery will not necessarily matter to you. What matters is that you get the medical treatment your doctor says you need.
There are several different ways to get approval for a surgery when the insurance company denies it. The best method for getting your surgery approved will depend on the particular facts of your case.
Talk to the insurance adjuster
The insurance adjuster should have the authority to approve or deny your surgery. This means that the insurance adjuster probably made the decision to deny your surgery. Sometimes, insurance adjusters can be persuaded to change their minds and approve a surgery that they have previously denied.
The insurance company may just not have a good understanding the surgery: Some common confusion that insurance companies have about surgeries include:
- What exact surgery the doctor is recommending
- Why exactly the surgery is needed
- How the surgery is related to your injury at work
You or an attorney may have to provide the insurance adjuster with additional information to show the adjuster these things. The insurance adjuster may also want a second opinion with another doctor before approving the surgery.
File a Form WC-PMT
Sometimes, you cannot get in touch with the insurance adjuster to get them to change their mind. Other times, you get in touch with them but they will not change their mind.
The Form WC-PMT (Petition for Medical Treatment) is a relatively new Georgia State Board of Workers’ Compensation form. It was created a few years ago to help solve the problem of insurance companies delaying treatment.
You have to follow certain rules to file a WC-PMT. But, when a WC-PMT is properly filed, it requires the insurance company to give an answer about whether they are authorizing or denying your treatment. If they do not give an answer, there is a phone call with a workers compensation judge about the recommended medical treatment.
Our office uses this form a lot to get medical treatment approved for our clients. Whenever a workers compensation doctor orders treatment, we start taking the steps that are necessary to file a WC-PMT. The first part of that process is communicating with the adjuster about the medical treatment recommended. But, if the adjuster does not approve that treatment within a week or so, we move forward with filing a WC-PMT.
Get the doctor to file a Form WC-205
The Form WC-205 is an older State Board of Workers’ Compensation form. Your workers compensation doctor can use this form to request approval for medical treatment.
The advantage of this form is that State Board rules require the insurance company to give an answer within five business days. If the doctor’s office follows the rules and the insurance company fails to respond in time, then the medical treatment should be authorized.
File a motion or request a hearing
Another option for getting surgery treatment approved involves getting the issue before a workers compensation judge. A judge can also get involved through the WC-PMT process mentioned above, but the insurance company can avoid the judge getting involved in that process by authorizing or denying the treatment.
Motions or hearing requests can help to get treatment approved. A motion or hearing request can result in an order from the judge approving surgery.
Of course, there is no guarantee that the judge rules in your favor. You also have to consider the time it takes to get a ruling on a motion or to receive an award after a hearing.