If you get injured at work and need surgery, you likely have a lot of questions about what happens next. Who approves your surgery? Once approved, who pays it? Under California workers’ compensation law, you’re entitled to reasonable and necessary medical treatment, but an insurance company might try to limit what they pay out by denying particular claims. We help fight back against delays and wrongful denials.
At Ratto Law Firm, P.C., our California workers’ compensation attorneys can help you get the surgery you need, and get it paid for. We seek to protect your rights every step of the way.
Your Right to Medical Treatment Under California Workers’ Compensation
California Labor Code §4600 requires employers to provide all medical treatment “reasonably required to cure or relieve” the effects of a work injury. This includes:
- Diagnostic testing
- Specialist evaluations
- Physical therapy
- Injections
- Surgery
- Post-operative care and rehabilitation
Who Decides Whether Surgery Is Necessary?
1. Your Primary Treating Physician (PTP)
Your PTP is the doctor primarily responsible for managing your care. They evaluate your condition, order tests, and determine whether surgery is medically necessary. Their recommendation is the foundation of the approval process.
2. Utilization Review (UR)
Once your doctor submits a Request for Authorization (RFA) for surgery, the insurance company must send it to Utilization Review. UR doctors, who never examine you, review the request to determine whether the surgery meets California’s medical treatment guidelines.
UR can:
- Approve the surgery
- Modify the request
- Deny the request
3. Independent Medical Review (IMR)
If utilization review modified or denies your surgery request, you can challenge that decision through an independent medical review. These are handled by the state, not the insurance company. If the IMR ultimately overturns the denial, the insurer has to authorize the surgery.
Who Pays for Surgery After a Work Injury?
If the surgery is approved through UR or IMR, the workers’ compensation insurance company pays for it. This includes:
- Surgeon fees
- Hospital or surgical center costs
- Anesthesia
- Pre-operative testing
- Post-operative care
- Medications
- Physical therapy
- Rehabilitation
You do not pay deductibles, co-pays, or out-of-pocket costs for authorized treatment.
What If the Insurance Company Delays or Denies Surgery?
Delays and denials are common, especially for:
- Back surgery
- Shoulder surgery
- Knee surgery
- Carpal tunnel release
- Rotator cuff repair
- Spinal fusion or disc replacement
If your surgery is denied:
- You can request IMR
- Your doctor can submit additional medical evidence
- You may be evaluated by a Qualified Medical Evaluator (QME)
- You can seek legal representation to challenge the denial
A denial does not mean you are out of options.
Can You Get Temporary Disability Benefits While Waiting for Surgery?
If your doctor says you cannot work or can only work with restrictions your employer cannot accommodate, you may receive Temporary Disability benefits while awaiting surgery. These benefits replace a portion of your lost wages.
If surgery is delayed due to UR or IMR, TD benefits may continue until:
- You undergo surgery
- You return to work
- Your doctor says you have reached maximum medical improvement
What If You Have Private Health Insurance?
If workers’ compensation delays or denies surgery, some injured workers consider using private health insurance. This is possible, but:
- Health insurers may require proof that workers’ comp denied the claim
- They may seek reimbursement later
- You may face co-pays or deductibles
- It can complicate your workers’ compensation case
Steps to Take If You Need Surgery After a Work Injury
- Follow up with your treating physician regularly
- Ensure your doctor submits a complete RFA
- Keep copies of all medical reports
- Track deadlines for UR and IMR
- Report any worsening symptoms
- Consider legal help if delays continue
Get the Help You Need After a California Work Injury: Speak with an Experienced Workers’ Comp Attorney Today
California law is designed to protect you and compensate you when surgery is required. Even if your employer tries to delay or limit your rights, we’re here to help.
Our team at Ratto Law Firm, P.C. provides you with the advice and representation you need. Contact us today for a consultation.