Most employers provide workers’ compensation for their employees if they become injured due to work-related activity. If you are hurt at work, these benefits help you pay your bills and cover your medical expenses.
The process of submitting a workers’ compensation claim varies depending on the nature of the claim and where you live. Still, sometimes insurers deny workers’ compensation claims, including medical services and surgeries.
Insurers deny claims involving surgery for various reasons, for example:
- The insurer determines that the injury is not a work-related injury or accident.
- The insurer determines that the procedure is not likely to cure your condition.
- The provider you choose for your medical care is not appropriately certified or approved by the Board.
How do claim denials happen?
In the case of surgical procedures, medical staff usually requests authorization from the insurer before the surgery takes place. If the insurer denies the claim, it will send a letter to the medical staff and often to the employee explaining why it rejected the claim.
Can I appeal the insurer’s denial?
Sure. You can dispute the insurer’s decision within a specific period of time, usually outlined in your employee benefits manual or available to you through your human resources department.
In some cases, the insurer will respond to your appeal by sending you a letter providing you with further information about why they decided to deny the claim.
In other cases, the insurer will ask the worker to get a second opinion or that you undergo an independent medical evaluation by a physician other than those who have been treating you.
Suffering a work-related injury is a difficult time for anyone, and going through the workers’ compensation claim process can add to that stress, making the situation even worse. In complex cases where many of the above examples are involved, you may consider seeking the advice of an experienced workers’ compensation professional.
