In every case, the insurance company has the right to send you to an independent medical exam (IME). This is an exam by a doctor of their choosing who often is not so “independent” and can mess up or at least delay your case. If your doctor says you need a surgery and the IME doc says you don’t then you’ll have a battle on your hands.
In some cases, the IME doctor is honest and finds in your favor. In others it’s so obvious that you need a surgery or were hurt at work that not even the worst hired gun can find against you.
When this happens it should be pretty straight forward that the surgery should be approved. That’s just common sense, right? Your doctor says you need it, their doctor agrees. There’s nothing to fight about.
One caller to my office had this exact situation happen to him and then the insurance company refused to approve the surgery. Instead they told him that they were having a “peer review” of the doctors. This is called a Utilization Review or UR. In a nutshell, they send your records to a doctor, often retired or out of state, to look at your medical records and make recommendations.
Does that sound like a joke? It often essentially is one, but is a strategy being used more and more because it’s cheap and it meets their end goal of saving money by denying cases.
All that said, in a situation like this, I can’t imagine if the worker had a lawyer who knew what they were doing that the surgery would get delayed. Even with the UR it’s unreasonable to delay the surgery because the insurance company is doing something called “doctor shopping.” In plain English that means you are stuck with the bad opinions of any doctor you choose and you can’t keep looking for a new opinion until you get one you like.
This applies to both insurance companies and injured workers. The difference is that when they act this unreasonably we can file a motion with an Arbitrator to not only get the surgery approved, but to have them pay you penalties for their bad behavior. I can’t imagine any insurance company trying to delay any further once the motion is filed.
The terrible part in all of this of course is that the injured worker has to suffer more and risks their long term health by delaying the surgery. Fortunately this behavior is so out there that we can usually get them to roll over right away.
