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Workers’ compensation insurance provides a way for employees to receive monetary support for on-the-job injuries and illnesses. California, like most states, requires employers to have workers’ compensation insurance, even if they only have one employee. Workers’ comp insurance pays for the costs of any work-related accidents. Sometimes, it can be tricky to determine when an injury or even a treatment is eligible for compensation. In certain situations, elective surgery can affect your workers’ comp case. Discuss the specifics with one of our Orange County workers compensation attorneys.
Not all work-related injuries or illnesses require surgery, but some of them do. Dependent on your employer’s compensation policy, you may need to see an approved doctor to file a compensation claim. That doctor will make a diagnosis and determine what treatment is necessary, such as surgery.
Section 4600 of California labor code requires workers’ comp to cover any treatment that would reasonably cure or relieve injured workers from the effects of their injury, including surgeries. If a physician determines the surgery is necessary, then it is eligible for a claim. However, insurers may not cover elective surgeries; the surgery must be a way to repair your injury.
Many people consider elective surgeries as unnecessary procedures. However, most people schedule elective surgeries well in advance, as opposed to emergency or urgent surgeries, which occur because of pressing medical conditions. Often, emergency and urgent surgeries occur in life-threatening situations where no other option is available for the patient’s survival.
As such, an elective surgery can still be medically necessary, just not needed immediately. These surgeries can help ease recovery from your injuries or help alleviate conditions of work-related illness. Depending on your condition, your workers’ compensation doctor may recommend an elective surgery as part of your recovery.
If your workers’ compensation doctor has stated that an elective surgery as medically necessary for your condition, it can then be part of your workers’ compensation claim. On the other hand, if you could have an elective surgery, but the doctor does not deem it part of your reasonable recovery, then it would not be eligible for compensation.
Matters of cosmetic surgery are also up for debate when it comes to workers’ compensation. While it may not seem necessary for recovery, some cases of serious injuries, such as burns, lacerations, and crushing require plastic surgery for proper recovery. As such, workers’ compensation may pay for cosmetic surgery in these situations or even when the accident compromised previous plastic surgery.
Doctors may not always deem a plastic surgery procedure medically necessary, though. It is up to the judgment of your workers’ compensation doctor whether you require plastic surgery to resolve your problem. Some cases where stitches have the potential to turn into scars may not seem as pressing to a doctor as they do to you.
If you have a disagreement with your doctor over their diagnosis, speak with one of our attorneys. Second opinions may not be an option in workers’ comp cases, but it may be an option for a personal injury case.
As with any workers’ compensation claim, the policy may deem your elective surgery ineligible for benefits. If this occurs, you have the right to appeal your case. If you complete the settlement conference, go through a trial, and are still not satisfied with the decision, you can file a Petition for Reconsideration.
While elective surgery may seem medically unnecessary, the specific case can determine otherwise. Receiving an elective surgery will affect your workers’ compensation case will vary depending on the purpose of the surgery if it is medically necessary for reasonable recovery and your consulting doctor’s opinion.
For specific help on your case, talk with an attorney to guide you through the process, help submit required workers’ compensation forms on time, and represent you in court if necessary.