What to Do if Surgery Is Denied by Workers’ Comp?

Workers’ Comp is a benefits program designed to help workers who sustained job-related injuries or illnesses.

In Mississippi, Workers’ Compensation provides medical care, as well as cash disability benefits. You can obtain the medical care you need after being injured at work, while having most—if not all—of the costs covered. However, it is not uncommon for work-related surgery claims to be denied.

If your Workers’ Comp surgery is denied, speaking with a Mississippi Workers’ Comp lawyer can help you understand your options and make it easier to get the care you need.

Why would you need surgery through Workers’ Comp?

Common reasons for surgery through Workers’ Comp

Anyone can be injured at work. Even something as simple as tripping on a bump in the floor can lead to life-altering surgery. And, with this in mind, some common reasons for surgery through Workers’ Comp are as follows:

• Slipping and/or falling on a wet, unstable, or rough surface.
• Fractures, tearing, and damage caused by heavy lifting/frequent stress.
• Burns from strong chemicals of intense heat.
• Damage to soft tissues, bones, and muscles caused by crushing against heavy machinery.
• Being hit in the eye with chemicals or dangerous materials.

Surgeries that Workers’ Comp can pay for

Workers’ Comp can pay for a multitude of different surgeries, as long as they are meant to address a work-related injury. Just a few of the surgeries that Workers’ Comp can pay for are as follows:

• Joint replacement surgery
• Carpal tunnel surgery
• Spinal fusion surgery
• Fracture repair surgery
• ACL reconstructive surgery

Why would surgery be denied by workers’ comp?

Workers’ Comp has the right to deny the surgery you need for many different reasons. Some of the most notable reasons are as follows:

• Workers’ Comp does not believe the surgery is necessary, or they believe an alternate treatment is better.
• You did not give your employer notice within 30 days of the injury.
• Your Workers’ Comp form contains missing details, incorrect information, or vague claims.
• You were not injured at work or from a work-related activity, or they don’t think you were.
• You did not present enough evidence to support the need for surgery.
• Your Workers’ Comp forms were not filed by the deadlines they specified.
• You filed your Workers’ Comp form more than two years after sustaining the injury.
• Your doctor asked you to follow specific medical guidelines, and you didn’t, or they don’t think you did.
• Workers’ Comp believes the surgery you need is due to a pre-existing condition, instead of a work injury.

Each one of the above can lead to your surgery being denied by Workers’ Comp. But even if your surgery is denied, you still have the right to appeal the denial. You may want to hire a Workers’ Comp lawyer to help you with this.

What to do if surgery is denied by workers’ comp?

Consult with a lawyer

Workers’ Comp denials are complicated. Navigating the “Why” of a denial and appealing this decision in the proper manner will likely not be an easy task.

You may want to consult with a Workers’ Comp lawyer who knows how to handle these cases. Doing so can make it a lot easier for you to navigate the denial process and, in doing so, get the surgery you need.

Go over the reasons for denial

To deny your surgery request, Workers’ Comp must have a reason. This reason could be one of which we specified earlier. Or, it could be for a completely different reason, related to something you may be unfamiliar with.

Regardless of why Workers’ Comp chose to deny your surgery, you must familiarize yourself with the reason for this denial. By doing so, you can file a claim to contest it.

File a petition to controvert

The first step to initiate a case before the Mississippi Workers’ Compensation Commission (MWCC) is to file a Petition to Controvert. A petition to controvert lets you clarify the workplace injury you sustained and detail what you are seeking from Workers’ Comp.

Soon after you file a Petition to Controvert, Workers’ Comp will assign a judge to your case. The judge’s assessment will lead to one of two outcomes: a negotiation between you and the other party, or a hearing in front of a judge.

Attend a hearing

If a hearing is ordered, you will need to present your case in front of a judge. And, when you do so, you must present evidence and arguments that support your need for surgery.

Just as an example, if you need a very expensive surgery for a fracture you sustained, you may want to bring an expert witness to the stand. This expert witness can validate your claims and convince the judge that you need the surgery you are requesting.

The other party will also be allowed to present their case. They may also bring expert witnesses and other forms of strong evidence. This is why working with a lawyer who knows how to navigate these hearings is often wise.

Conduct a negotiation

A hearing may be unnecessary. Your employer may opt for negotiations. And, as a result of these negotiations, you and your lawyer may be able to obtain a settlement.

If the negotiations go well, this settlement may encompass the surgery you need. But, if it doesn’t go well, you may receive some form of compensation, albeit not the compensation you are seeking for the surgery you require.

Appeal the judge’s decision to the commission

In the event that the judge rules against you, you have one last chance to file an appeal. To file this appeal, you must do so within 20 days.

Within this appeal, you must tell the MWCC why you disagree with the judge’s decision. The other party must do so, as well.

The Commission typically reviews the case based on the record and written briefs rather than holding a new evidentiary hearing.

In the event that the Commission agrees with your claim, you will likely get the surgery you need. But if they disagree, you could bring your case to Mississippi’s courts.

Get in touch with a Mississippi workers’ comp lawyer

A denial is not the end. You can get in touch with the Mississippi Workers’ Comp lawyers at Merkel & Cocke, P.A. by using our contact form. We are ready to help you.