The Workers’ Compensation Insurance Company Won’t Pay for My Surgery

insurance company won't pay for surgery

The PA Workers’ Compensation Insurance Company won’t pay for my surgery. What can I do?

The Pennsylvania Workers’ Compensation Law says that a Workers’ Compensation Insurance Company has to pay for reasonable and necessary medical treatment from a licensed provider on its face related to the accepted injury listed on the Notice of Compensation Payable or in the Judge’s Decision.

Unfortunately, there is no pre-certification requirement. The Workers’ Compensation carrier doesn’t have to say “yes” or “no”, until the surgery has been performed and the provider files the proper paperwork with the Workers’ Compensation insurance carrier.

What is the injured worker supposed to do?

  1. File a Petition for Penalties requesting a Workers’ Compensation Judge to fine the carrier for refusing to pay.
  2. File Utilization Review whereby the Bureau of Workers’ Compensation appoints an outside doctor to determine whether the surgery is reasonable and necessary.
  3. In some cases, file a Petition to Review to ask the Workers’ Compensation Judge to expand the Description of Injury in the Notice of Compensation Payable. This would be done in a case where the accepted injury is “shoulder sprain” and the treating physician wants to perform an ulnar nerve release which was caused by the original injury.
  4. Have non-Workers’ Compensation insurance pay for the surgery in the meantime. Be careful. The non-Workers’ Compensation insurance carrier may have a form to fill out which asks the patient whether or not the surgery is work related. (“Check the box, yes/no”) The injured worker should not check either box. If you say yes, the surgery may be denied. If you say no, the defense attorney will use this against you in a future Workers’ Comp hearing. Don’t check either box,; write in: “WC denied”. If possible, attach a copy of the Workers’ Compensation Denial. In this way, you can get the surgery paid for, then follow steps 1 and 2 above and get the non-WC carrier paid back later.