What to Do If Worker’s Compensation Denies A Medical Procedure

One of the most frustrating things about dealing with worker’s compensation is dealing with the insurer itself. It’s not uncommon for your doctor to recommend a treatment, only to have the insurance company deny coverage for it.

It seems intensely unfair. How can an insurance adjuster, who never went to medical school, look at you and your doctor and tell you that your procedure isn’t “medically necessary?“

Or, how can they say the procedure that’s been proposed has nothing to do with the injury you took on the job, when it’s so clear and obvious that it has everything to do with it?

See also: Repetitive Stress Injuries and NJ Worker’s Comp.

The problem is, insurers stay in business by looking for every reason to deny coverage they can find. They aren’t really concerned with straightforward common sense or fairness. They’re concerned with making a case that allows them to avoid payment. 

They may agree to cover a lesser or less effective treatment, or they may deny coverage altogether. Fortunately you have some recourse. You can appeal this decision, and there are ways for you to get treatment in the meantime.

Step 1 – Gather Documentation

Go back to your doctor and have him or her provide full documentation as to why he or she believes this procedure is medically necessary. You’ll need this to refute the insurer’s claim.

Step 2 – Bring the Matter to Your Lawyer

Your lawyer can make a claim on your behalf, and can make sure a claim hearing happens.

This will give you the opportunity to introduce evidence that the procedure is both medically necessary and relevant to the injury you took while on the job.

Step 3 – Use Your Regular Health Insurance

Nothing is stopping you from having your normal health insurance policy cover the process. Of course, they could deny the claim as well, but that’s a separate issue. Often, they’ll cover it, especially since they’re indifferent to the cause of the injury. 

If you do this, you’ll still incur costs…but in the meantime, you’ll get the surgery you need. 

Step 4 – Wait For Results

If your worker’s compensation lawyer is successful in arguing in favor of your claim, then the worker’s compensation insurer will have to pay your insurance company, reimburse you for your costs, and pay your legal fees.

See also: Delays in Your Worker’s Compensation Claim: What Can You Do?

It Pays to Have a Lawyer

Snags like this are just one of the many reasons why it’s important to have a good worker’s compensation lawyer on your side after you suffer from a major injury at work. Without a lawyer’s help, curve balls like this are difficult to manage and deal with. 

See also: 5 Ways You Can Lose Your Worker’s Comp Benefits in New Jersey.

If you’re having trouble with your worker’s compensation claims, call Talone Law today for a free consultation.