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When Your Doctor Says You Need Surgery and The Insurance Company Says No - A Well-Worn Road in Workers' Compensation

Posted by James Aspell | Apr 28, 2023 | 0 Comments

Workers' compensation is designed to protect employees who are injured on the job. This system ensures that employees receive the medical care they need and compensation for lost wages. However, the process can be complicated, and some employees may find themselves in a difficult situation when their insurance company denies their claim for surgery.

The process of filing a workers' compensation claim and getting approval for surgery can be a long and challenging road. Many injured workers  find themselves in a difficult position when their doctor recommends surgery, but the workers compensation insurer insurance company denies their claim.

In this article, we will discuss the steps you can take when your doctor says you need surgery, but your insurance company says no. We will also provide tips for filing a successful workers' compensation claim and getting the medical care you need.

  1. Understanding Workers' Compensation

Workers' compensation is a system that provides medical care and financial compensation to employees who are injured on the job. In Connecticut, workers' compensation is mandatory for most employers, and the benefits are provided at no cost to the employee.

Under workers' compensation, employees are entitled to reasonable medical care for their work-related injuries. This care can include doctor visits, surgeries, physical therapy, and other treatments. Additionally, employees may be entitled to lost wages and compensation for their pain and suffering.

  1. Filing a Workers' Compensation Claim

If you are injured on the job, it is essential to file a workers' compensation claim as soon as possible. In my state, Connecticut, This is done by filing a Form 30C Claim for Compensation.  The process for filing a claim may vary depending on your state, but generally speaking, you will need to report your injury to your employer and fill out a claim form.

After you file a claim, your employer's insurance company will investigate the accident and determine whether to approve or deny your claim. If your claim is approved, you will receive medical care and compensation for lost wages.

  1. Getting Approval for Surgery

If your doctor recommends surgery for your work-related injury, your next step is to get approval from your employer's insurance company. This process can be challenging, and many insurance companies deny surgery claims.To increase your chances of getting approval for surgery, it is essential to provide your insurance company with as much information as possible about your injury and the surgery your doctor recommends. This information can include medical records, test results, and a letter from your doctor explaining why surgery is necessary.  The liklihood of your surgery being denied increases if you have made several work comp or car accident claims in the past, especially if you have claimed prior injury to the body part that your doctor is seeking to perform surgery on. 

  1. Appealing a Denial

If your insurance company denies your claim for surgery, you have the right to appeal their decision. The appeals process can be complicated, and Connecticut, it can be time-consuming.  If the insurance company is denying responsibility for your surgery, it is critical to have an experienced workers compensation attorney on your side. Your attorney can help you gather additional evidence to support your claim and represent you during the appeals process. If your appeal is successful, you will receive the medical care you need, including surgery.

  1. Working with a Workers' Compensation Attorney

If you are injured on the job and need surgery, it is essential to work with a workers' compensation attorney. An attorney can help you navigate the complex workers' compensation system and ensure that you receive the medical care and compensation you deserve.

Additionally, an attorney can help you appeal a denial of your claim for surgery and represent you during the appeals process. With an attorney on your side, you can focus on your recovery and getting back to work.

When your doctor says you need surgery, and your insurance company says no, it can be a challenging and frustrating experience. However, with the right information and resources, you can fight for your rights and get the medical care you need.

By understanding the workers' compensation system, filing a successful claim, and working with an attorney, you can increase your chances of getting approval for surgery and receiving the compensation you deserve.

About the Author

James Aspell

Principal since August 1, 2006 James F. Aspell is the principal and managing attorney of the firm which he started in 2006 following 20 years of litigation practice in a mid -size firm in Hartford, Connecticut. Jim focuses his practice in the areas of worker's compensation and personal injury l...


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