Does Having Surgery Increase Your Workers’ Comp Settlement?

When you have been hurt on the job, workers’ compensation is meant to take care of your medical bills and get you back to work as soon as possible. In most cases, this includes all treatment and care you require, even surgery. However, depending on what the surgery is, whether it’s recommended by your doctor, and the timing, it can have a significant effect on your workers’ compensation settlement.

It can be confusing to know whether having surgery increases your workers’ comp settlement. To understand the nuances, you may want to schedule a free consultation with a skilled workers’ compensation attorney who can assess your case.

How Workers’ Compensation Works in Pennsylvania

As a quick reminder, the Commonwealth of Pennsylvania requires employers to provide workers’ compensation insurance coverage for all employees, with some exceptions. The coverage will provide benefits for those who are injured or become ill while performing their work duties. Benefits include partial wages while you are out of work and medical expenses for your recovery.

To submit a successful claim, you will need to report your condition in a timely manner, visit an approved physician or medical facility, and participate in your treatment to reach recovery and return to work. If you are permanently disabled, whether partially or totally, you can receive further payments and treatment. Each case is unique, and an experienced workers’ compensation attorney can advise you on the specifics of your claim. 

Does Workers’ Comp Pay for Surgery? 

Yes, workers’ compensation insurance should pay for your surgery if it is recommended as part of your treatment by an authorized doctor. In some cases, you may face issues getting a surgery approved for a variety of reasons, such as if the procedure is experimental or if it costs much more than a different surgery that could achieve similar results.

If you have an injured spine, neck, or joints, your surgery may be more expensive and require a lengthy recovery period. You are more likely to be disabled for a longer time away from work and to suffer a permanent disability. Workers’ comp should pay for all surgeries you need, but when you have the procedures done can affect your settlement. 

Likewise, if you will need substantial physical or occupational therapy after surgery, your workers’ compensation attorney can guide you in calculating a fair sufficient estimate of your projected needs. Without accounting for the necessary treatment after surgery, you could be left unable to fully recover and return to work. 

How Do I Get Workers’ Comp Surgery Approval From the Insurance Company?

In most cases, if your physician has recommended surgery, your workers’ comp insurance company will cover it. However, the company is interested in more conservative treatments because they cost less. They may review your case and ask you to try medications and physical therapy first. While this may alleviate some of your issues, if the surgery is truly needed, this delay could worsen your injury.

Your health is the most important factor in determining whether to perform the surgery. The goal should be to allow you to fully recover from your injury and be left without pain or impairment. However, if you elect to have surgery that your physician didn’t recommend, you choose an experimental procedure, or you attempt to have surgery that isn’t related to your injury, you are risking a denial of benefits.

The best path to achieving approval from the workers’ compensation insurance company is to ensure it’s necessary for your recovery and will give you the best chance of getting back to full health. Ultimately, your employer is interested in your ability to return to work, so you must consider their viewpoint in your decision while keeping your health as a top priority. 

Should I Settle My Case Before Surgery? 

Your workers’ compensation insurance will examine your requested surgery and determine if it is necessary, reasonable, and related to your on-the-job injury. Depending on the procedure and your circumstances, it may be better to settle before the surgery. Conversely, some situations will leave you with a better settlement if you wait until after the treatment.

Critical factors that you and your attorney should consider include:

  • If you want the surgery
  • How well you are functioning currently
  • What the offered settlement amount is
  • The timing of the procedure
  • The doctor you want to perform your surgery
  • The chances of whether workers’ comp will cover your surgery if there is a dispute
  • The possibility of another insurance company paying for the surgery

If you settle before your surgery, you will have the freedom to use whatever doctor and facility you desire, and you’ll receive your money sooner. If you wait until after the procedure, you will have to use an authorized surgeon and rely on the workers’ comp insurance company to pay your bills. If you have personal insurance from your spouse’s employer or another medical insurance company, you may have more flexibility in making your decision. 

How Do I Settle a Workers’ Comp Claim?

In Pennsylvania, you can settle your workers’ compensation claim by choosing a lump-sum payment. This is called compromise and release. You may accept a single large payment, or your settlement may be structured, where you are paid at regular intervals until you receive the full amount. 

Regarding surgery, you are likely to need initial emergency care, which could include surgical procedures. Those will be covered, but the questions most people around paying for surgery have to do with ones that come later in your recovery. For example, you may spend months working to rehabilitate back or leg injuries when it becomes clear that you need additional surgery to fully recover.

Because of this, most workers’ comp insurance companies won’t make an offer to settle for a lump sum until as long as a year after your injury. You are still entitled to your regular benefits, but you may need to conduct careful negotiations with them for the money you need for your surgery. 

What Does a Workers’ Comp Lump Sum Settlement Include?

Each case will be unique depending on the worker’s specific situation. In most instances, the workers’ compensation insurance company will ask you for a settlement demand once it becomes clear that you are seeking to litigate the case. They will want to close the claim out quickly and for as little as possible, which is why you shouldn’t handle these negotiations on your own. 

In situations where the worker is permanently disabled and won’t improve medically beyond their current level, the insurance company may offer an amount intended to cover future medical care and lost income. This can be attractive, but it’s essential to ensure you’ve calculated your own estimate of what you’ll need so you aren’t left with too little. 

With a skilled workers’ comp attorney, you can present a full and fair settlement demand that includes all your current and projected medical costs, as well as your past and future lost wages. 

Get Help With Your Worker’s Comp Claim Today

For guidance on managing your workers’ compensation benefits, including surgeries, get in touch with the experienced team at Krasno Krasno & Onwudinjo. Contact us for a free consultation today.

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