Minor surgery, the saying goes, is surgery involving someone else. When you’re the one drifting off under anesthesia, there’s nothing minor about any concerns you’re having.
Likewise, when surgery is part of your claim it can play a major role in the workers comp settlement you’ll receive.
A number of factors affect workers compensation settlements, such as:
- The extent of the injuries.
- Time away from work.
- The degree to which a person may be disabled.
- Future medical costs as a result of a workplace injury or illness.
Surgery can be just another factor impacting the value of a settlement, or it can be the overriding reason your settlement increases by thousands of dollars.
Not surprisingly, surgery’s impact on a settlement is often in direct proportion to the seriousness of the surgery, the type of work injury and the long-term prognosis for a return to full health.
Does Workers Comp Pay for Surgery?
Workers comp insurance provides coverage to assist employers in paying for medical expenses and other costs related to workplace injuries and illnesses.
Workers comp generally covers medical expenses and disability benefits. Under the umbrella of medical expenses, necessary surgery is typically covered, as are emergency room visits, medications, hospital stays, ongoing care and physical rehabilitation.
How Workers Comp Claims Are Calculated
The calculation for disability benefits is based on your average weekly wage. The insurance company arrives at that number using your pre-injury earnings.
That calculation is predicated on your gross wages, including any overtime or bonuses. But don’t expect to receive 100% of your average weekly wages, even if you’ve routinely left a shiny apple on your superior’s desk.
Typically, workers comp will pay two-thirds of your average weekly wages. Workers comp experts advise that employees check the homework done by the insurance company in this regard. Mistakes are made. It’s critical to make sure your average weekly wage isn’t underestimated.
Minimum and maximum amounts are predicated on the statewide average weekly wages (SAWW) at the time of your injury or claim filing.
In addition to disability benefits and medical coverage (your workers comp insurer is responsible for the entirety of your reasonable medical costs), workers comp insurance covers any costs involved in retraining for a new job, financial compensation if injuries are permanent and survivor benefits for families if a worker is killed on the job.
How Surgery Affects a Workers Comp Settlement
There’s no such thing as cut-rate, discount surgery (thank goodness) so generally speaking, surgery will add significantly to a workers comp claim and settlement.
The cost of the surgery depends on the seriousness of the injury, although cost for identical surgeries can also fluctuate by state.
If your workers comp doctor concludes surgery is necessary, workers comp insurance should cover the costs. Just know that the insurance company’s doctor might recommend more conservative (less expensive) steps such as therapy and rehabilitation first. Their goal, after all, is to minimize the company’s payout if at all possible.
That’s why taking a settlement offer from your workers comp insurer before you know the seriousness of your injuries or whether you might eventually need surgery, is a risk.
The kind of procedure you need will determine how much surgery can affect a settlement. For instance, the average cost of surgery for carpal tunnel is less than $10,000. A joint replacement could cost between $16,500 and $33,000. For a severe back or spinal injury, the cost can be as much as $150,000.
Will surgery affect the timeline of your settlement? Will it prolong the process?
“In general, surgeries have the potential to slow down the timeline of a workers’ compensation settlement,” said Sarah Thomas, managing partner at Jones Jones LLC in New York City. “This is because the injured workers often want to have the surgery done, as well as some healing time and possible post-operative treatment completed prior to the settlement of their claims.
“In the majority of states, a workers’ compensation settlement equates to a permanent closure of both the medical and indemnity (money) of the claim. The potential of the medical aspect of the claim being closed permanently may concern an injured worker and that is the reason they want medical stability around the time of settlement negotiations.
“Pending surgery or recent surgery may be a turbulent time for an injured worker, thus either scenario can certainly affect the timeline of the settlement.”
The workers comp insurance company must approve the surgery and may ask for a second medical opinion before agreeing to cover the costs.
You don’t have much recourse if a second opinion is requested for whatever reason, whether it’s because insurance doesn’t believe surgery is necessary or it’s looking for a less expensive option. Refusing to get a second opinion could put your workers comp benefits at risk.
If you and the insurance company agree surgery is necessary, then the only delay is in scheduling the procedure.
Workers Comp Settlement Before Surgery
If you plan to settle your workers comp case before having surgery, at the very least, you should have a lawyer read the settlement papers.
“If a case is settled prior to surgery, ideally the settlement papers would be drafted, signed and moved before the courts so that the settlement is formalized and closed,” Thomas said. “The details of the settlement and the surgery payment should have been completely vetted during the negotiation process so both sides of the agreement are completely clear as to how the surgery will be scheduled and completed after the settlement of the claim.”
So, if settlement precedes surgery, employees need to make sure the settlement amount reflects the possibility of future surgery (or surgeries) and any complications that may arise. The settlement amount needs to cover the expenses to come: hospital stays, anesthesia, physical therapy, follow-up visits, pain relievers and any complications or setbacks.
Consulting with an experienced workers comp attorney can help protect your interests, whether you receive a lump sum settlement or a structured settlement.
Workers Comp Settlement After Surgery
Say you’ve suffered an injury that required immediate surgery. Your workers comp insurance should cover the costs of that surgery, ambulance trip (if necessary) and other related medical costs.
Any post-surgery settlement should still account for the possibility of future surgeries and the other costs previously mentioned.
“Settlement after surgery is typically more common than settlement prior to surgery,” Thomas said.
Workers comp claims and settlements can be confusing, especially for employees going through the process for the first time. The spiraling costs related to surgery makes it even more important for employees to protect their interest.
It can be the difference between a minor nuisance and a major headache.
About The Author
Tom Jackson won dozens of national awards as a columnist for newspapers in Washington, D.C., Sacramento and Tampa. His writing has spread from business to politics to sports with an emphasis on community issues. Tom splits his time between Tampa and Cashiers, N.C. with his wife of 40 years, a college-age son and a yappy Shetland sheepdog named Spencer. Tom can be reached at email@example.com.
- N.A. (ND) Workers’ compensation and payments. Retrieved from https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance/workers-compensation-and-payments
- N.A. (2019, March 27) Medicaid Liens and Workers Comp. Retrieved from https://www.natlawreview.com/article/medicaid-liens-and-workers-com