In a normal world, your treating doctor stating that you need treatment would be enough to get it approved as long as you were injured at work. That’s not how Illinois workers’ compensation law works unfortunately. In a lot of cases, your doctor says you need surgery and the insurance company sends you to their own doctor. That hired gun says you don’t need surgery and now all of the sudden your work comp benefits are denied.
The solution to this problem is to go to trial. The question is, how do you win a trial to get medical benefits approved so you can get the treatment you need and not have to pay for it?
While every case depends on the facts, the #1 thing an Arbitrator will look for is, is the surgery your doctor wants to do reasonable. By that I mean is it a common surgery that is medically accepted? Or is it an experimental procedure that isn’t yet widely used. The more common it is, the more likely it is that it will be awarded.
The second thing an Arbitrator looks for is the likelihood for success if you have that surgery. This is where your attorney’s effort and knowledge comes in to play. They will need to take the deposition of your treating doctor and have them testify as to how likely it is that the surgery will succeed. The higher the percentage, the better chance you have to win. On the flip side, even if the insurance company doctor doesn’t think you need a surgery, it’s helpful to get them to admit that it’s usually a successful procedure.
The surgery doesn’t have to make you 100% for it to be considered successful. Instead it has to make you better. If your pain before surgery is 9/10 and ends up as 3/10 when you done healing from surgery, that’s considered a success in most cases.
The third factor that an Arbitrator looks at are the risks of the surgery. If there is a decent chance it could make your situation worse it might not get approved. If it might not work because you are smoking and won’t quit, it might not get approved. If you want a back surgery and there is a risk of paralysis if it goes wrong, you might lose your case.
Like any other trial, winning comes down to the facts, your credibility and the credibility of your doctor versus their doctor. And of course if you have an attorney with a track record of success in winning these claims, that helps your chances a lot too.
If you have any questions about getting a medical procedure approved after a work injury or anything else, contact us any time for a free consultation. We help everywhere in Illinois.
