Workers Comp Surgery Secrets Every Injured Worker MUST KNOW!!!

Whether you're wondering how surgery affects your benefits, how long your case might take, or how to choose the right doctor, we've got you covered. Let's break it down and make this journey a little easier for you.

How Does Surgery Affect Your Workers' Comp Case?

If your surgery is causally related to your workplace injury, meaning it's necessary due to the injury you sustained at work, you are generally entitled to receive benefits during your recovery period.

In many cases, if you undergo surgery and are unable to work while you recover, you can receive temporary total disability benefits. These benefits are typically two-thirds of your average weekly wage, subject to a statutory maximum. This helps cover your lost income while you are out of work recuperating.

However, there are exceptions. For example, if you were not actively seeking work before your surgery and are not considered "attached to the labor market," your benefits might be denied even after surgery. It's essential to stay engaged in the work search process if you're not currently employed to maintain your eligibility for benefits.

Surgery can also make your case take longer to resolve. This is because the recovery period and reaching Maximum Medical Improvement (MMI) can extend the timeline of your case. MMI is the point at which your condition has stabilized and is not expected to improve further with or without medical treatment. Only after reaching MMI can the true extent of your permanent disability be assessed, which is crucial for determining the final settlement or compensation.

Can the Need For Surgery Increase the Value of Your Case?

Yes, the need for surgery can increase the value of your workers' compensation case, but it depends on the circumstances.

If the surgery is causally related to your workplace injury, the time missed from work during recovery is compensable, and future surgery needs (like a knee replacement) can add value to your settlement.

However, surgery's purpose is to improve your condition, which may reduce your level of permanent disability—a key factor in determining settlement value. New York does not compensate for pain and suffering, so the number of surgeries alone does not guarantee higher compensation. Proper documentation by your doctor is critical for valuation.

The Key to Getting Surgery Approved

The key to getting surgery approved in a workers' compensation case is having a doctor who understands how the workers' compensation system works. In New York State, the Workers' Compensation Board uses an online Portal System where doctors submit reports and requests for treatment authorization.

A doctor must follow the state's medical treatment guidelines, document treatments properly, and request any necessary variances through the system. A knowledgeable doctor who adheres to these requirements is crucial for getting surgery authorized quickly and effectively.

Insurance companies may try to prevent surgery approval in a workers' compensation case by:

-Attributing the need for surgery to preexisting conditions

-Claiming insufficient documentation of conservative care (e.g., lack of physical therapy or injections before surgery)

-Stating there’s no documentation of objective improvement from prior treatments

They may also deny surgery if the doctor's treatment plan does not align with the medical treatment guidelines. It’s essential that the doctor thoroughly documents the treatment and follows the system to counter these tactics.

What if Surgery is Denied?

If surgery is denied by the insurance company, the key is to have a knowledgeable doctor who can address the denial reasons effectively. The insurance company must provide a specific reason for the denial, and the doctor can use this feedback to make a new request or appeal.

Ensuring that all documentation, including conservative care and treatment progress, is thorough and aligned with workers' compensation guidelines is essential. Persistence and having a doctor who understands the system can help overcome the denial and move the case forward.

Do You Get to Choose Your Surgery Doctor?

Yes, in New York State, you are free to choose your treating doctor for surgery in a workers' compensation case, as long as the doctor accepts you as a patient.

To ensure you choose the right doctor, you can:

-Consult with your lawyer

-Talk to friends or family who have been through the system

-Check online reviews

Or use the Workers' Compensation Board's website to search for doctors by specialty and location. It’s important to select a doctor who is knowledgeable about workers' compensation to ensure a smooth process.

What to Consider Before Deciding on Surgery

Before deciding on surgery, you need to talk to your doctor about the expected outcomes, including the pros and cons. Ask detailed questions to fully understand the procedure, its purpose, and what it aims to achieve. Discuss what you can realistically expect in terms of regained function, movement, and strength.

Here are some key questions to ask yourself when considering surgery:

1. What are the expected outcomes?
   • What improvements in function, movement, or pain relief can I expect?
2. What are the risks and potential complications?
   • Are there any serious risks or side effects I should be aware of?
3. What is the recovery process like?
   • How long will it take to recover, and what kind of support will I need during that time?
4. What happens if I don’t have the surgery?
   • Will my condition worsen, improve on its own, or stay the same without surgery?
5. How will this impact my workers’ compensation case?
   • Could delaying or forgoing surgery affect my benefits or settlement?
6. Am I mentally and emotionally prepared for surgery?
   • Do I feel comfortable and confident in my decision?
7. What alternative treatments have I tried?
   • Have I explored all other options, such as physical therapy or injections?
8. What are the long-term implications?
   • Could I need further surgeries or treatments down the road?
9. Do I trust my doctor?
   • Am I confident in my doctor’s expertise and their recommendation for surgery?
10. What are my financial and insurance considerations?
    • Will this surgery be fully covered, and what costs might I need to cover?

Answering these questions can help you make a well-informed decision.

What if Surgery isn't Successful?

If surgery wasn’t successful, it does not necessarily negatively impact your workers' compensation case. Your condition post-surgery will still be assessed for its level of permanent disability, which is a significant factor in determining the value of your case.

Workers' compensation does not award benefits for pain and suffering, so the focus remains on your functional recovery and ability to return to work. If the surgery fails to improve your condition, it could potentially increase the level of permanent disability, which may increase the value of your settlement. However, each case depends on its specific circumstances and documentation.

In some cases, if a long-term condition or permanent disability is established due to the unsuccessful surgery, additional benefits or compensation may be pursued to address ongoing medical care and lost earning capacity.

Pro Tips For Injured Workers Needing Surgery

1. Choose a Knowledgeable Doctor:
   • Ensure your doctor understands the workers' compensation system, including the Portal System and medical treatment guidelines, to properly document and request treatments or surgeries.
2. Be Honest About Preexisting Conditions:
   • Disclose any prior injuries or conditions to avoid allegations of fraud. Open and honest communication strengthens your case.
3. Document Everything:
   • Make sure your doctor thoroughly documents all treatments, progress, and the necessity for surgery to counter potential insurance company denials.
4. Understand Your Surgery:
   • Ask your doctor detailed questions about the procedure, risks, benefits, and expected outcomes. Having realistic expectations helps in making an informed decision.
5. Work with an Experienced Lawyer:
   • Consult your lawyer for advice on doctors, handling denials, and navigating the workers' compensation system.
6. Use Available Resources:
   • Research doctors on the Workers' Compensation Board website, read reviews, and seek recommendations from friends or family who have been through the system.
7. Be Prepared for Insurance Company Tactics:
   • Insurance companies may deny surgery due to preexisting conditions or insufficient conservative care. Having a strong medical record and a skilled doctor is critical.
8. Consider Future Needs in Settlements:
   • If you may need future surgeries, document this with your doctor and factor it into settlement negotiations.
9. Know Your Rights:
   • You cannot be forced to have surgery, and if you choose not to proceed, you may still settle your case or reopen it later if necessary.
10. Stay Attached to the Labor Market:
    • If you are required to search for work and fail to do so before or after surgery, your benefits could be at risk. Keep records of your job search efforts.
11. Expect a Timeline Reset Post-Surgery:
    • Surgery typically resets the clock for determining permanency and maximum medical improvement, potentially extending the timeline of your case.
12. Ask for Help:
    • Don’t hesitate to reach out to your lawyer or trusted contacts for guidance throughout the process.

Contact Us For Help With Your Workers' Compensation Case

Dealing with a workers' compensation case can be challenging, especially when surgery is involved. It's important to have a solid understanding of both the medical and legal aspects to ensure you get the benefits you deserve. If you have any questions or need guidance, don't hesitate to reach out.

I'm here to help you navigate the complexities of your workers' compensation claim. Whether you need advice on medical treatments, help with documentation, or simply want to know more about your rights, I'm available to assist you. Feel free to give me, Rex Zachofsky, a call at 212-406-8989. Let's work together to get you the support and compensation you need during this time.