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Still waiting on my Workman's comp insurance to approve my surgery!

Sparky123SSparky123 Posts: 133
edited 06/11/2012 - 7:25 AM in Back Surgery and Neck Surgery
X( ~X( :W Even though I'm having my Pre Op physical tomorrow, my workmans comp insurance still hasn't approved my surgery! I called my lawyer today and they said they have a hearing set up for Friday to ask a judge to force the insurance company to give us an answer on the surgery (good or bad). Whats really pissing me off is I went to my I.M.E appointment (set up by the insurance company) over 2 weeks ago and THEIR doctor said I definitely need this surgery, but I still haven't gotten an official evaluation from that appointment. My lawyer said they sometimes wait to give you a response until you either A. "Get a hearing with a judge", or B. Give up and say "Screw it, I don't want the surgery anymore." Either way, its longer of a wait for them that they have to put out money for surgery. He also said going to a judge in a clear cut case like mine is really stupid on their part because in the end their putting out money for a surgery and also having to pay their lawyers to work on the case.

I'm hoping this is just me getting all worked up over nothing because before I got a lawyer, I personally had to work with the insurance company to get everything approved, and nothing ever got denied. They were just really slow at approving things.

OK, I'm done venting. Thanks for listening.


  • sorry you are going through this...my treatments and surgery were also worker's comp..but I have to say I am very lucky. Quick approvals for everything. Do you know the name of your caseworker? I contacted mine directly and "nicely" explained my situation. she was very receptive and helpful. Doctor was impressed with the quick approval.

    I hope it all works out for you. Dealing with comp on top of dealing with pain really sucks. Sorry
  • Hi there,

    I was a workers comp case and can thankfully say the process wasn't too bad. I think the key is what state you are in.

    Some states have terrible laws regarding W/C. In Kentucky, I was able to get through my whole two year window without having a lawyer and still receieving very good medical care plus receieve a fair settlement.

    Even if you have a lawyer, read the laws in your state to become familiar with them. Also, most states have a workers comp ombudsman in the Dept. of Labor Cabinet that should be able to help. You can ask them questions and they will give you an idea of what to expect. They won't represent you as counsel, but they can let you know what is right and wrong.

    I wish you the best!

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
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  • First of all, this is long, but worth reading. You are absolutely going through exactly what I went through with our wonderful work-comp system. I injured my L-3,4,5 on the job 20 months ago, lifting too much weight, what I'd give to take that day back. After jumping through the work-comp hoop of 3 of their surgeons telling me I needed a 3 level lumbar fusion, then they sent me to a 4th (IME) cause work-comp insurance company DIDN'T want to hear that I needed surgery. Well this 4th jerk, and I sincerely mean that... no eye contact, manipulating me into positions, that I cried through due to the pain, told the insurance company "surgery denied".

    I was litterally on the pre-op exam table with the little gown on and a EKG machine hooked up to me, of course making sure I was healthy enough to have the surgery, when I had a doctor run into my room stating, "wait, she hasn't been approved yet by the insurance company". My exam stopped, and I cried at that point, due to the pain, and I had mentally prepared myself for this major surgery.

    That was when they sent me to the 4th IME doctor, and he told the insurance company that I did not need surgery! After 3 of their surgeons that THEY sent me to said that I absolutely needed the surgery. I had before all this had 4 cortisone injections, did PT, which all doctors told me that it would do more harm than good. (but did it anyway on the advise of my attorney) Physical therapist even wrote a letter stating such.

    After I received the letter that stated "surgery denied" that was after 15 months of their "hoops", they just left me laying on the couch and bed, and did absolutely nothing else. Just left me that way.

    I layed around on my couch and bed for 4 months following the horrible news in excrutiating pain, crying a lot, not knowing what to do. At this point it had now been 17 months since my injury. My attorney was absolutely worthless as far as advise, (I ended up firing him due to that)

    Thank god, I had my OWN health insurance through my husbands employment. I thought, what's it going to hurt to give them a call, explain my situation, tell them the whole story in what happened with the work-comp people. For those 4 months of laying around, I did not think my insurance would help me, due to it being a work related injury. I set an appointment with one of the best Neurosurgeons in Colorado and MY health insurance company. Took in all my MRI's, x-rays and reports from W/C surgeons. MY insurance could not believe what I had been through after viewing my MRI, they said that "3 months is conservative treatment, not (then at this point 18 months after injury) 18 months", then my Neurosurgeon stated, "because of this length of time of W/C not doing anything, your injury is worse". He immediately took new MRI's and x-rays, viewed them, and it was no time at all, that I was having my 3 level PLIF fusion performed. When my surgery was finally performed it had been 23 months after injury, by MY health care. THANK GOD!!

    THEN I hired a new attorney, because I saw lawsuit written all over this. BUT, guess what, it didn't happen that way. Common since tells anybody that this whole mess was wrong. BUT what happened in court absolutely brought me to tears, as I still sit here healing from my 3 level fusion.

    I was told by the Judge (totally on work-comp's side) "why didn't you contact your claims adjuster after you were denied for surgery"? My jaw about dropped when he stated that. I told him, "why would I contact him, when I was told "surgery denied"?

    What it turned out to be was, I was to wait for 2 years (W/C statute of limitations), do 2 years of cortisone injections, physical therapy, BUT had I done that, I still would not of been fixed, then according to the W/C laws, my case would have been dropped, and THEY would not have been responsible for my injury anymore! Amazing hu?

    So seeings that I went OVER W/C's head, went to my OWN health insurance provider to get fixed BEFORE the 24 months, I was due ANY compensation!!! really....

    I did end up with only 34k, should have been around 150k. BUT, I have to look at it this way.... I finally got fixed by one of the top Neurosurgeons in Denver, (which I'm really glad cause W/C had me go to a quack Orthopedic Surgeon that loses paperwork, that was suppose to do my surgery at one point) I'm now 9 months post-op coming along slowly, but coming along, my original pain is gone, but this surgery takes approximately 2 years to heal from, and got a little cash in my pocket, and I'm finally rid of that whole mess!

    So like I said, good luck buddy.. If you have any other questions, PM me, I'll be glad to answer any of your questions. In the meantime, I really feel for you and hope you have some other insurance.

    It didn't ake
  • I can't give you any advice since I am not going through WC, but I just wanted to wish you good luck. Hopefully you can get this figured out in time for your surgery. My only piece of advice is document everything. Every phone conversation, etc. Good luck! >:D<
  • Like I said before, their doctor said I need surgery (along with the 2 docs I saw) so I'm guessing it will be approved sooner or later. Technically I still have 22 days till my surgery, but my lawyer seems to be on the ball. I guess he had this hearing set up 2 weeks ago just in case they dragged their feet on the approval. I'm pretty sure if they tried sending me to another I.M.E my lawyer would say "No way!" and ask for a trial.

    Either way, I'm sick of waiting! ~X(
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  • I am in Australia so I know it will be different but I really empathise with you as I have been on workers comp now for 7 years.
    I cant tell you how many hoops they have had me jump through and how many times they ahve had me in tears and/or fits of rage and frustration.

    I recently discovered that there is a governing body here called work cover so I went to them for help. I was told that if I send in a request for surgery, scans or anything else then the insurance company had 3 weeks in which they must reply. They also have to pay any reimbursement within 2 weeks (I have waited 3 months in the past) and there are a lot of toher rules they and I need to follow.
    SO please do some research and get all the facts and figures that you can so you can call them up on it is necessary.

    The thing is they want you to give in but I will be blowed if i am going to let them win! So take lots of deep breaths and hang in there.

    Blessings Sara O:)
  • Found out today they still haven't contacted my lawyer, so I will have to go to court on Nov. 20th. My lawyer said a lot of times they will wait till the last minute to approve it so I'm supposed to call him the day before to see if they have made a decision. He also said insurance companies sometimes would rather be told what to do than make a decision on their own, so he's going to bring every bit of evidence with him to court just to make fools out of them =D> . Either way I will know for sure if I'm approved for the surgery or not on the 20th. Wish me luck! :SS
    Hopefully all will be approved and you will go through with your surgery without a hitch.
    Sorry you have this extra burden though.
  • Sparky123 said:
    X( ~X( :W Even though I'm having my Pre Op physical tomorrow, my workmans comp insurance still hasn't approved my surgery!

    I am sorry that you are going through this! I got hurt on 10/4/06. I just had another mri done, I am also dealing with workcomp. I am on my third lawyer right now with this case :T . So far they are great though.

    I am now waiting to get the results and make a appt. with a neurosergeon. I hope that they will just approve it without going to a hearing. The sad thing is that the judge could approve it, and they can still appeal. They love to play those games X(

    I hope that everything works out for you. I also have never been paid my biweekly benefits, they just appeal everything for me :''( .
  • I am a tiny bit familiar with the last minute thing. My surgeon, the day I saw her for my reherniation, she called the Vascular surgeon right in front of me to see if he could switch around his schedule to take me the next morning, and she said she was switching hers around because her first case was a workman's comp case that hadn't yet been approved... So that was right up until 12 hours before that person's surgery they were still waiting for approval. However, my doctor's office tends to book things fast, so maybe they just didn't have enough time to get it approved through WC. I hope yours gets approved when you go to court!!
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