Injured workers ask can workers comp deny surgery after they have already been paying medical bills and disability benefits? The answer should be no, but yes they do it all the time.
Wisconsin worker’s compensation law states that “The employer shall supply such medical, surgical, chiropractic, psychological, podiatric, dental, and hospital treatment, medicines, … as may be reasonably required to cure and relieve from the effects of the injury, … The obligation to furnish such treatment and appliances shall continue as required to prevent further deterioration in the condition of the employee or to maintain the existing status of such condition whether or not healing is completed.” Wis. Stats. Sec. 102.42(1).
What happens in many cases is once the workers compensation insurance adjuster realizes that the injured worker may need surgery, they start to look for a reason to deny the claim so they do not have to pay for surgery and all the time off that comes with a neck or back surgery. The usual defense plan is to have you see their “independent medical examiner.” Because your doctor or surgeon is already recommending surgery as necessary due to the work-related injury, the only way the worker’s comp insurance company can get out of paying for the surgery is by having another doctor disagree and give a contrary opinion. When there are two opposing medical opinions, it becomes a question for the worker’s compensation administrative law judge at a hearing.
We can go to a hearing on the question of whether worker’s comp has to pay for the surgery. This is called a prospective treatment hearing under Wis. Stats. Sec. 102.18(1)(b). Often injured workers needing surgery do not want to go to hearing just on the surgery question. The reason is if the injured worker has what may be a large claim to worker’s compensation money benefits but a weak causation link; going to hearing on prospective treatment could bring a premature end to an otherwise promising and substantial case. Rather than going for a prospective treatment order, if the worker has health insurance, he or she could use that and then resolve any potential subrogation interest in a future hearing or compromise.
If the best option is an application for hearing seeking prospective treatment, the attorney should be prepared to file: 1) a medical opinion that the proposed treatment is necessary to cure and relieve the employee from the effects of the injury; and 2) identify the specific nature of the treatment or procedures sought. McCormick Law Office attorneys get the best results on surgery cases when the surgeon fills out paperwork before the surgery. We work for injured workers throughout southeastern Wisconsin.
