If you were injured on the job, you may be entitled to benefits covering the cost of any treatment you need. The legal team at Calhoon & Kaminsky P.C. is here to explain how surgery can increase a workers’ comp settlement and what to consider when you need surgery for a workplace injury.
To learn more about how surgery can affect a workers’ comp settlement in Pennsylvania, contact our office for a free consultation.
How Is My Workers’ Comp Settlement Calculated?
In Pennsylvania, workers’ compensation covers the cost of all medical care required for a workplace injury. It also provides weekly wage-loss benefits. Workers’ comp will pay you two-thirds of your pre-accident wage if you cannot work at all. If you can only work in a restricted position with a reduced income, workers’ comp will pay you two-thirds of the difference between your pre- and post-accident wages.
You may choose to settle your case with your employer’s workers’ comp insurance provider. Depending on its terms, this will end your benefits in exchange for a lump-sum payment or structured payment plan. There are several factors an insurance company will look at to determine their settlement offer, including:
- The value of your weekly wage-loss benefits
- The cost of your future medical care
- The way your injuries may impact your future earning potential
Because every case is different, it’s difficult to determine an average workers’ comp settlement for surgery. To calculate a rough estimate of your workers’ comp, multiply your compensation rate by the number of weeks your injuries will continue to affect your employment — up to the 500-week maximum. Add that number to the expected cost of necessary medical treatment. That should give you a fair estimate of what you should receive in a workers’ comp settlement.
How Can Surgery Affect My Workers’ Comp Settlement?
Workers’ compensation benefits will cover the costs for all reasonable and medically necessary expenses related to treating your injuries. If you can show that surgery is a necessary part of your treatment, you can likely include the cost of surgery in your settlement. Because surgery is an expensive medical procedure, it can significantly increase the value of a workers’ comp settlement.
What Types of Surgery Does Pennsylvania Workers’ Compensation Cover?
The type of surgery does not determine whether it is covered in your workers’ compensation settlement. What matters is:
- Whether the surgery is medically necessary
- When the surgery will happen
- Whether you had already agreed to a settlement before having the procedure
Workers’ compensation should cover the costs of any necessary medical procedure while your claim is open. If you choose to end your claim through a settlement, you should factor in the costs of any future surgeries your doctor thinks you will need before you sign the compromise and release agreement.
If you have already accepted a settlement that did not include the cost of surgery, you will likely have to pay for it out of pocket or through your health insurance. You typically cannot go back to renegotiate a settlement you have already accepted. However, a workers’ comp attorney can fight to include language in your agreement providing coverage for other medical expenses.
Should I Get Surgery and Then Settle? Or Vice Versa?
There is no specific rule on whether you should have a surgical procedure while your workers’ comp settlement is pending or wait for the final settlement agreement. Every situation is different. Here are some factors to consider:
- Your overall health and how the surgery will improve your bodily functions
- When you want the procedure
- Whether you want to use an employer-approved doctor
- The chances of your settlement covering your surgery
- How likely is it that the insurer will dispute your workers’ comp claim
- Whether another insurer might cover the surgery
- The amount you are offered in a settlement
Talking to a Pennsylvania workers’ comp lawyer can help determine whether you should wait to have surgery after settling.
How Long Will It Take for Workers’ Comp to Approve My Surgery?
If your claim is still open, your employer’s workers’ compensation provider should approve the cost of any necessary procedure in a timely fashion. The insurance company needs to accept your claim first, usually within 21 days from when you reported the injury. You may need to then have the surgery approved, which can require multiple doctor’s visits.
The answer is different if you have already settled your claim. If you agreed to a simple lump-sum payment, you don’t need approval because the cost of your surgery is on you. But if your settlement included insurance coverage for future surgeries, the process should be similar to the one outlined above.
What Factors Determine If Workers’ Comp Will Cover My Surgery?
If your initial workers’ compensation claim was approved and you have not agreed to a settlement, your employer’s insurer will cover the cost of any surgery required for your workplace injury. If you have agreed to a settlement that provides coverage for necessary surgeries, the insurance should pick up the tab. However, you will need to pay the costs yourself if you have settled your claim and the terms of the agreement do not cover future surgeries.
Can I Choose My Doctor If Workers’ Comp Pays for My Surgery?
In most Pennsylvania workers’ comp cases, you must use a doctor approved by your employer for the first 90 days after your first medical appointment. After 90 days, you can select any doctor to perform your surgery. You may need to wait if you want a particular surgeon to perform your procedure.
What Should I Do If the Insurance Company Refuses to Pay for My Surgery?
Contact a Pennsylvania workers’ comp attorney immediately if an insurer will not pay for a surgery you need. A workers’ comp lawyer can help you gather additional medical evidence and file an appeal to get the necessary treatment.
Contact a Workers’ Compensation Lawyer in Pennsylvania to Explore Your Options
The Pennsylvania workers’ compensation lawyers at Calhoon & Kaminsky P.C. are ready to help you get the medical treatment you need after a workplace injury. Contact our office today for a free case review.
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For more than 20 years, our attorneys have been helping injured workers navigate the complex Pennsylvania workers’ compensation system. We empower workers with the information and the representation they need to make the best decisions for themselves and their families’ future.
