By: Michael J. McConnell, White Plains workers’ compensation attorney
Having an insurance company deny your doctor’s request for surgery related to a work injury can feel devastating.
You are in pain and out of work. The surgery is supposed to make you better. Why won’t the insurance company cover it?
And more importantly: how do you get them to approve it?
In this article, White Plains workers’ compensation lawyer Michael J. McConnell explains the following:
- Reasons why surgery might get denied.
- How to challenge a denial of a surgery and get it approved.
- Why hiring a workers’ compensation lawyer can be critical in fighting back against a denial.
- Important steps to take after surgery gets approved.
Common Reasons Why Surgeries are Denied on White Plains Workers’ Compensation Cases
The insurance company might deny a request for surgery for several reasons. Here is a list of the most common ones:
- The surgery is not related to a body part or injury that is covered on your claim.
- The surgery is inconsistent with the New York State Medical Treatment Guidelines (MTGs) based on the current medical documentation.
- Causation is disputed.
- Your entire claim is denied.
- The surgery isn’t medically necessary.
- The doctor the insurance company hired to do an “Independent Medical Exam” disagrees with your doctor that you need surgery.
- Your doctor didn’t properly submit the request, which resulted in denial based on a technicality.
Some denials can be proper, but many lack appropriate justification. Even for seemingly correct denials, sometimes additional documentation can solve the problem.
With that said, a concern for many is that the insurance company might deny or delay a necessary surgery to try to save costs. When that happens, it is important to push back until that surgery gets approved.
How to Get a Surgery Approved Through Workers’ Compensation After an Initial Denial
If the insurance company denies your doctor’s request for surgery, the first step is to identify the reason for the denial. Knowing why they denied the surgery is critical for determining how to best challenge it.
Here are some examples of situations that are fairly common:
If surgery is denied because the particular body part is not covered under this work accident, then it will be important to try to amend the claim to include that body part.
If the surgery was denied for being inconsistent with the New York State Medical Treatment Guidelines (MTGs), you need to analyze the MTGs and determine two things:
- Whether the insurance company properly applied the MTGs for the denial. If they didn’t, then you can challenge the denial as improper and the surgery might get approved upon further review.
- If the denial correctly applied the MTGs, then what steps can be done to fix that issue? For example, sometimes surgery isn’t appropriate under the MTGs until at least a course of physical therapy has been tried. If that is the case, then your doctor can consider sending you for PT and upon completion can re-request the surgery if needed.
If your claim is controverted or denied in its entirety, then the surgery might not be approved until you can get the denial overturned. This can require significant litigation before the New York State Workers’ Compensation Board. If you are successful in reversing the denial and the surgery is otherwise medically appropriate, then it might ultimately be approved.
If causation is disputed or the insurance company claims the surgery isn’t necessary, this can also require litigation. Often it will be your doctor’s word against the opinion of the so-called “Independent Medical Examiner” that the insurance company hired. After depositions, the judge will determine who is more credible on causation. If the judge agrees with your doctor, the surgery might be approved.
Having Legal Representation for your White Plains Workers’ Compensation Case is Often Essential in Challenging a Denial
In New York, you have a right to an attorney on your workers’ compensation claim.
Figuring out what to do after a denial of a surgery that your doctor strongly says you need can feel confusing and beyond overwhelming.
The savvy insurance company and their adjusters deal with the MTGs and all things workers’ compensation related all day every day. They are also for-profit machines who have an incredibly strong incentive to try to pay the least amount possible on your case so that they can maximize profits.
When you get blindsided by a denial and call them up to ask them about it, you might get the runaround. They might use a bunch of jargon that hardly makes sense.
They keep talking about technicalities and it sounds so detached from reality. The bottom line is this:
You are injured and need surgery to make you better. Why are they making this so complicated?
Having legal counsel to fight back against an improper denial of surgery on your workers’ compensation case can make all the difference. A diligent lawyer will know what to look for and the best way to get the surgery approved if possible.
Additionally, successfully challenging a denial of a surgery often requires litigation – including depositions of doctors. A qualified lawyer will know how to aggressively cross-examine the insurance company’s “Independent Medical Examiner” and make powerful legal arguments to the judge on why your surgery should be approved.
More than anything else, a workers’ compensation lawyer may give you peace of mind knowing that whatever happens on your case that you will not be taken advantage of or shortchanged by the insurance company.
The Most Important Steps After a Surgery Gets Approved for your Work-Related Injury
If you are successful in getting the denial of the surgery overturned, it is often beneficial to do the following things:
- Advise the insurance company of the surgery date once scheduled so that they know to either start paying you for lost wages or adjust to a higher rate due to the surgery.
- If you need postoperative treatment, durable medical equipment, or in-patient rehabilitation after your surgery, make sure the insurance company confirms it has been approved. Undergoing surgery can be stressful and the last thing you want is a problem trying to get appropriate post-op care.
- Send copies of the operative report to the insurance company and the Workers’ Compensation Board once available.
- Continue to follow up with your doctor regularly as recommended and adhere to their treatment plan, which may consist of things like physical therapy or a home exercise plan.
By being proactive and taking the steps above, injured workers can often avoid common pitfalls and hiccups related to an approved surgery. It also can be highly impactful to have a White Plains workers’ compensation attorney representing your interests who can do these things on your behalf so that you can focus on your recovery.
Conclusion: Denials of surgery can be challenged and reversed. Having a White Plains workers’ compensation lawyer fight for your right to get the medical care that you need can help you get the surgery that you need.
Surgeries are common for work-related injuries in White Plains. While the insurance company might initially deny the surgery, they don’t get the final say. There are ways to challenge a denial and often having an attorney to fight for you can make all the difference. If your surgery ends up getting approved, it is important to get all the necessary information to the insurance company and the Workers’ Compensation Board so that there are no problems with getting paid for lost wages and getting the postoperative care that you require.
If you have been hurt at work in White Plains, please contact the Law Office of Michael J. McConnell right now for a free consultation.
Michael J. McConnell is a Westchester County workers’ compensation lawyer. He is a graduate of Pace Law School in White Plains. He is a former NYC prosecutor who prides himself on treating every case with the seriousness that it deserves. He also has tremendous insight regarding how insurance companies handle and evaluate claims as he previously worked for a major insurance carrier for over five years handling New York workers’ compensation cases – many of which were in the White Plains and Westchester County area.
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