Workers’ Comp Settlement Before or After Surgery?

A surgical operation can sometimes be necessary after you get injured at work. What many employees want to know is whether workers’ compensation will pay for the surgery, and whether they should settle before or after the operation. Here are answers to some common questions about workers’ comp and surgery in Virginia.

Does workers’ comp pay for surgery in VA?

Yes, workers’ compensation covers surgery recommended by the employee’s treating physician. Virginia’s workers’ compensation law requires employers and their insurers to pay for all necessary and reasonable medical care associated with the worker’s on-the-job injury.

As the injured worker, you’ll need to prove that your injury is job-related and that surgery is a reasonable treatment for it so that you can obtain these medical benefits. Having a workers’ comp lawyer can greatly help you do this.

Does having surgery increase my workers’ comp settlement?

Generally, if it is very likely that you need surgery, or if your attending physician recommends surgery, your workers’ comp value may increase as surgical procedures are expensive. However, actually having the surgery does not guarantee a higher settlement amount. Consider these scenarios:

• If the surgery leads to a full healing of your injury and you suffer no long-term pain or impairment afterwards, the settlement amount could be less than expected. By contrast, injuries that require long-term care can drive up the settlement amount.
• If you opted to have surgery but the insurance company decides that it wasn’t necessary, they could refuse to pay for the procedure.

It’s wise to have an attorney guide you on your best options for maximizing worker’s comp. When it comes to surgeries, it’s vital to prioritize your health, but it’s also not advisable to go through a procedure just for the sake of increasing your claim value.

Can I settle my workers’ comp case before surgery?

Yes, it’s possible to receive a workers’ comp settlement before you have surgery. However, there are pros and cons to this option.

These are some advantages of settling your workers’ comp claim before surgery:

• You may be able to negotiate for a larger settlement amount by including the projected cost of your necessary surgery.
• You can choose your surgeon and surgery date. After you receive your settlement money, you’ll no longer need the authorization of the insurance company for your doctors and date of procedure.
• You won’t have to worry anymore about the insurer denying your claim or pushing the case to litigation.

And these are some disadvantages of settling your claim before surgery:

• You’ll have to pay out-of-pocket for your surgery.
• You don’t know yet whether you’ll have permanent work restrictions after the procedure. If you’ve already received your settlement but have a persisting impairment after the operation, you can no longer claim additional medical benefits.
• There’s the possibility of surgical complications that could cause you more expenses. These will no longer be compensable after you’ve settled. By contrast, if you wait until after the surgery to get a settlement, you may be able to have the insurer cover any surgical complications or post-surgery disability.

If you are trying to decide when to settle your workers’ comp claim, consult with a lawyer who is experienced in the intricacies of the Virginia workers’ compensation system.

How do I get worker’s comp surgery approval from the insurance company?

The two main factors you’ll have to prove are 1) that your injury is compensable under Virginia law, and 2) that surgery is a reasonable treatment for this injury. Unfortunately, many workers’ comp insurers still refuse to authorize surgery, even for employees who have an Award Order. The insurance company might give various reasons for denying surgical authorization, such as:

• They have an “Independent Medical Examiner” (IME) who says your surgery is not necessary for your injury.
• Their IME says that the recommended surgery isn’t likely to help your condition.
• They find that you have not exhausted other treatments that are more conservative.
• The surgery recommendation came from a physician that they have not authorized.

How long does the insurer have to approve my surgery?

Sadly, there is no time limit for insurance companies to approve or deny a surgery request. Many insurance adjusters will prolong the case or simply not respond, in hopes that you’ll give up your claim. What can prompt them to take your request seriously is if you get a lawyer and file a claim with the Virginia Workers’ Compensation Commission. We discuss this in the next section.

What do I do if the workers’ comp insurer denies my surgery?

First, it’s valuable to know why the insurance company rejected your request. Ask the insurance adjuster for the specific reason for their denial.

At this point, you’ll want the guidance of a worker’s compensation lawyer. You have the option to file a claim with the Virginia Workers’ Compensation Commission to reopen your case and get authorization for your surgery. You’ll need compelling evidence and arguments to support your claim, that’s why your attorney will be indispensable during this process.

The Commission will then order the insurance company to respond within 30 days as to whether they approve or deny your surgery request. If the insurer rejects it, your case will go to hearing so that the Commission can decide on your claim.

You may have your surgery while your claim is pending. If you win your case, the workers’ comp insurance company will have to pay for the procedure, even if it’s already been paid (by your health insurance, for example). However, if your claim is unsuccessful, you’ll have to shoulder your surgery cost. Consult with your lawyer to weigh the risks and options you have for your claim.

Talk to a Trusted Virginia Workers’ Comp Lawyer

It can be challenging to get your surgery covered by workers’ comp insurance, so you’ll need a lawyer who can advocate for your rights. Workers in Virginia trust Attorney Jaleh K. Slominski, an experienced worker’s compensation lawyer whose work has led to favorable settlements for her clients.Ms. Slominski is not afraid to fight for you even when faced with powerful companies and insurers.

Talk to Attorney Slominski about your surgery worker’s comp concerns. Contact us by email, or call (434) 384-9400 (in Lynchburg) or (540) 554-3762 (in Roanoke).