Your doctor recommends surgery for a workplace injury, but the insurance company has not approved it. Waiting can be stressful, especially if your condition is getting worse.
New Jersey workers’ compensation covers necessary and reasonable medical care for work-related injuries. This can include surgery when medically appropriate. The insurer may question whether you need surgery or whether it stems from your workplace injury, which can delay approval.
Why might surgery approval be delayed?
The insurer may review your medical records, imaging results and treatment history before approving surgery. It may question whether the procedure is necessary or directly related to your workplace injury.
New Jersey law generally allows your employer or its insurance carrier to choose your authorized treating provider. Your doctor’s recommendation and medical records can help explain why you need surgery. However, the insurer may still challenge the request. Ask your authorized provider whether the insurer needs more information before deciding.
What should you do while waiting?
While you wait for a decision, take these steps:
- Keep copies of your doctor’s recommendations, test results and communications about the surgery request.
- Ask your authorized provider whether the insurer needs more records to support your request.
Follow your treatment plan where possible. Tell your provider about changes in your symptoms or any problems attending appointments.
What if the insurer delays or denies surgery?
You may be able to seek help through the New Jersey Division of Workers’ Compensation. Your options may include requesting an informal hearing, filing a formal claim petition or filing a motion for medical and temporary benefits. The Division’s guidance on resolving workers’ compensation disputes explains these options.
If delaying treatment could cause irreparable harm or damage, you may be able to request emergent medical treatment through a separate process. Under N.J.S.A. 34:15-15.3, your physician must document the urgent medical need and the specific harm that delaying treatment would cause. Not every surgery delay qualifies and specific requirements apply.
A Judge of Compensation can review your case and decide whether workers’ compensation law covers the treatment you need. If the delay affects your health or recovery, keep your medical records current and seek legal advice.
Take the next step
A delay in surgery approval can affect your health, recovery and workers’ compensation claim. Knowing your options under New Jersey workers’ compensation law can help you make informed decisions about your treatment and recovery.