Hurt on the job in South Carolina? You may be entitled to workers’ compensation benefits. Many employers in our state are required to provide no-fault workers’ comp insurance to employees as a matter of law. Workers’ comp covers reasonable and necessary medical expenses, including emergency care and surgeries. This raises an important question: What should you do if workers’ comp denies your surgery? The short answer is that you have the right to appeal the insurance company’s decision. It is imperative that you take immediate action. In this article, our Moncks Corner workers’ comp attorney provides an overview of the steps to take if your claim is denied.
Know the Law: Workers’ Comp Covers Reasonable and Necessary Medical Care in SC
Workplace accidents happen. Workers’ comp insurance is designed to provide protection to employees. The South Carolina Workers’ Compensation Law requires all companies and organizations in the state with four or more employees to provide those workers with no-fault workers’ comp coverage. Some small employers (one, two, or three employees) obtain workers’ comp insurance as well. If you are covered and were hurt at work in South Carolina, you have the right to medical care through the workers’ compensation system.
A key thing that you should know about workers’ comp in South Carolina is that it provides medical coverage. Indeed, the law requires your employer’s insurance carrier to pay for treatment that is both reasonable and necessary. To be clear, that includes surgery when doctors confirm it is required to treat your condition. Unfortunately, as strong as the law is, it can still be challenging for some injured workers in Moncks Corner and elsewhere in the Lowcountry to get their benefits. Insurance companies sometimes deny claims by arguing that surgery is not needed, is too costly, or is unrelated to your job injury. A denial is not final. You have the right to challenge the decision.
Steps to Take After a Workers’ Compensation Surgery Denial
Was your surgery denied by workers’ comp in South Carolina? It is crucial that you take action to protect your health, your well-being, your financial interests, and your legal rights. A proactive approach is a must. A Moncks Corner, SC work injury lawyer with experience handling appeals can help. Here are five important steps to take after a workers’ comp surgery denial in SC:
- Step #1: Review the Written Denial Notice: Under South Carolina law, you should receive a letter explaining why your surgery was denied. As a starting point to challenging a denial, you should read and review. Read this notice carefully because it sets out the insurance company’s reasoning. The denial may cite lack of medical necessity, preexisting conditions, or incomplete documentation. You need to understand why the insurance company claims that it made the decision that it did.
- Step #2: Gather and Organize All Medical Records: Medical evidence is key to raising a successful appeal. Your medical records are the foundation of your appeal. Collect treatment notes, test results, and the surgical recommendation from your physician. These documents show why the surgery is necessary and connected to your workplace accident. Having a complete medical file makes it harder for the insurer to unfairly deny your surgery.
- Step #3: Seek a Second Medical Opinion: In many cases, surgery coverage will be denied based on the opinion of a doctor that the insurance company retained. They do not get to make the final call on their own. A second opinion can strengthen your case. Another qualified doctor may confirm that the surgery is the best option for recovery. Insurance companies often take a second medical opinion more seriously during the appeals process.
- Step #4: Challenge the Finding By Requesting a Hearing With the South Carolina Workers’ Compensation Commission: If the insurer still refuses to authorize the surgery, you can ask for a hearing with the Commission.. The South Carolina Workers’ Compensation Commission reviews disputes between injured workers and insurance carriers. You or your attorney files the appropriate forms, submits supporting evidence, and requests a hearing. It is the formal process for challenging the denial. .
- Step #5: Attend the Workers’ Comp Hearing: Assuming no settlement can be reached, your case will move towards a hearing. At the hearing, you and your Moncks Corner workers’ comp lawyer can present medical records, expert testimony, and legal arguments. Of course, the insurance company will argue its position as well. The commissioner acts like a judge and issues a ruling after reviewing all the evidence. A well-prepared presentation is key to getting your surgery approved at the hearing.
- Step #6: Consider an Appeal to the Full Commission or Courts: If the commissioner rules against you, you still have options. It is your right to go to the next level. You can appeal to the Full Commission for a broader review. Beyond that, a further appeal can be filed directly to the South Carolina Court of Appeals.
Can You Get a Workers’ Comp Settlement After Surgery?
Yes. Even if surgery was not approved, and it already happened, you can still move forward with your claim. In other words, you may be entitled to a settlement even after surgery. In South Carolina, workers’ comp settlements are often negotiated after treatment is complete. The settlement can include compensation for permanent disability, future medical needs, and wage loss. The fact that you required surgery already could (potentially) increase the overall value of your claim. Insurance companies understand that surgery signals a serious injury. If you need surgery because your work injury was that bad, you should not accept a settlement without speaking to a lawyer.
Why Trust Our Moncks Corner Workers’ Comp Attorney
Dealing with the aftermath of a serious job-related accident can be challenging. It is normal to have a lot of questions about your rights and your options, especially if your surgery has been denied. At the West Law Firm, we put injured workers and their families first. Our team handles all aspects of claims, including workers’ comp appeals. With a proven record of case results, you can count on us when it matters the most.
We have an office right here in Moncks Corner. Notably, Moncks Corner is the county seat of Berkeley County. It is home to a wide range of employers in manufacturing, construction, healthcare, and public service. Job-related injuries are regularly reported in the area, from worksite falls and equipment accidents to repetitive stress injuries. Our local office positions us to represent injured workers in Moncks Corner, across Berkeley County, and throughout the Lowcountry.
Contact Our Moncks Corner Workers’ Compensation Lawyer Today
At the West Law Firm, our Moncks Corners workers’ comp attorneys are always prepared to go the extra mile for injured workers. If your surgery was denied, we are more than ready to help. Call us now or contact us online today for your free, no obligation initial consultation. We handle workers’ comp cases in Moncks Corner (29461) and throughout the Lowcountry of South Carolina.