Does Surgery Increase a Workers’ Compensation Settlement?

Workers’ Compensation Coverage for Surgeries and Other Treatments

North Carolina General Statute 97-25(a) says simply, “Medical compensation shall be provided by the employer.” To that we can add, “Or their workers’ compensation insurance.” Under North Carolina workers’ compensation law, your employer’s insurance should cover all medical treatment reasonably necessary to effect a cure, provide relief, or lessen the period of disability. This coverage extends beyond just the initial surgery to include:

Pre-surgical consultations and evaluations with specialists who determine the need for surgery and develop your treatment plan

Hospital and surgical costs, including anesthesia, operating room fees, and surgical team costs

Post-operative care, such as follow-up appointments, wound care, medication management, and any necessary medical equipment

Rehabilitation services, including physical therapy, occupational therapy, and other treatments needed to help you recover function

Prescription medications, such as pain management medications and other drugs prescribed as part of your treatment plan

Medical devices and equipment, including crutches, braces, wheelchairs, or other assistive devices needed during your recovery

Costs for traveling to medical appointments, including mileage reimbursement, for appointments more than 10 miles each way, or 20 miles round trip. Unfortunately, there is no compensation for travel less than that.

While workers’ compensation insurance must cover medically necessary treatment, getting approval for surgery isn’t always straightforward. Insurance companies tend to review surgical recommendations with an eye toward questioning whether the procedure is essential for your recovery in order to minimize their costs.

Working with experienced legal counsel can give you the support you need to receive authorization for necessary surgical procedures without unreasonable delays. Your attorney can help document the medical necessity of your surgery and advocate for you if the insurance company tries to deny or delay approval.

If your treating physician recommends surgery but the insurance denies authorization, your attorney can file a medical motion with the North Carolina Industrial Commission (NCIC) for an order authorizing the treatment.

How Can Surgery Increase Your Workers’ Comp Settlement?

Before answering this question, please understand that the decision to have surgery or not is a medical decision, not a legal decision. It is a decision to be made between you and your doctor only. No settlement money can ever fully compensate you for an unnecessary surgery. Your health is far more important than any amount of money any lawyer can get for you.

That being said, surgery can significantly affect your workers’ compensation settlement in several important ways. Insurance companies evaluate settlements based on how much money the settlement will save them. Period. Settlements have never been, and probably never will be, about fairness.

Some ways that surgery can drive up the costs that the insurance company wants to avoid are:

Long-term medical needs – Surgery often requires ongoing follow-up care, rehabilitation, and potential future procedures. Your settlement should account for all future medical costs related to your workplace injury, including possible revision surgeries or additional treatments.
Recovery time and lost wages – Surgical procedures typically require substantial recovery periods when you cannot work. Your settlement should include compensation for lost wages during your recovery.
Permanent restrictions – Some surgeries may result in permanent physical limitations that affect your ability to perform certain job duties. If these restrictions prevent you from returning to your previous position or reduce your earning capacity, your settlement should reflect these long-term wage losses.
Disability ratings – When you reach maximum medical improvement (the point at which no additional treatment will improve your condition) after surgery, and the injured body part is not 100% back to its pre-injury baseline, your doctor may assign a disability rating. This rating helps determine the value of your permanent disability benefits and can significantly influence your settlement amount.
Complications and additional treatment – If your surgery leads to complications or requires additional procedures, these factors can increase the overall value of your claim. A fair settlement should account for any unexpected medical issues that arise from your treatment.

The key to maximizing your workers’ compensation settlement after surgery is to document all these costs properly and ensure they’re accurately reflected in settlement negotiations. An experienced workers’ compensation attorney can gather the necessary medical evidence and expert opinions to support the full value of your claim.

Surgery Factors That Can Affect a Workers’ Compensation Settlement

Several key factors can influence your workers’ comp settlement for surgery. Understanding these elements helps set realistic expectations about your claim.

Timing of Surgery

Settlements offered before surgery tend to be lower than those negotiated after surgical completion, as the full extent of your medical needs becomes clearer. Most insurance companies will assume that if you are trying to settle before having the surgery, that you will decide to not have the surgery after the settlement. They may “call your bluff” by “low balling” you in negotiations. Your attorney can advise you on the optimal timing for settlement discussions.

Type of Surgical Procedure

More complex surgeries typically result in higher settlements due to increased recovery time and potential complications. Having multiple surgeries may increase a workers’ comp settlement value as well because each procedure adds medical expenses and often indicates a more serious underlying condition.

Surgical Outcomes

The success or limitations that result from your surgery play a crucial role in settlement value. A procedure that fully restores function may result in a different settlement than one that leaves you with permanent restrictions.

Age and Overall Health

Your age and pre-existing conditions can affect surgical recovery and, consequently, your settlement value.

Return to Work Potential

Your ability to return to work after surgery significantly influences settlement negotiations. Surgery on one body part may affect your ability to return to work more than surgery on a different body part. Permanent work restrictions or the need to change careers due to surgical limitations often increase settlement values.

Does Workers' Comp Have to Approve Your Surgery?

Here’s what you need to know about the workers’ compensation medical claim process:

Medical necessity – Your treating physician must document why the surgery is necessary for your work-related injury. This includes showing that more conservative treatments have failed or would be ineffective.
Authorization process – The insurance carrier reviews your doctor’s surgical recommendation and supporting medical evidence. They may require additional medical opinions or examinations before granting approval.
Second opinions – If the insurance company questions the need for surgery, they may require you to see another doctor for an independent medical examination (IME). You have the right to request your own second opinion if you disagree with their physician’s assessment.
Emergency situations – The standard approval process may be expedited in cases requiring immediate surgical intervention. However, you or your attorney should still notify the insurance carrier as soon as possible. The NCIC has both an expedited and an emergency medical motion procedure as described in Industrial Commission Rule 609A.
Appeals process – If your medical issue cannot be resolved with a medical motion, it may go to a full evidentiary hearing. The loser at a full evidentiary hearing can appeal to a three-judge panel of the Full Industrial Commission. The loser at the Industrial Commission can appeal to the North Carolina Court of Appeals.

An experienced workers’ compensation lawyer can guide you through this process and present compelling medical evidence supporting your need for surgery.

How Our Attorneys Can Help with Your Workers’ Comp Settlement

When you need surgery for a workplace injury, having experienced legal representation can make a crucial difference in your case outcome. Our attorneys at Younce, Vtipil, Baznik & Banks, P.A. provide comprehensive support throughout your workers’ comp claim by:

Building strong medical evidence – We work with your healthcare providers to document the necessity of your surgery and its connection to your workplace injury.
Handling insurance communications – Our team manages all interactions with the workers’ compensation insurance carrier, protecting your interests during settlement negotiations.
Calculating full claim value – We carefully assess all aspects of your case, including future medical needs, to seek a fair settlement that adequately covers both current and long-term expenses.
Protecting your rights – If the insurance company attempts to deny or delay surgical approval, we will advocate aggressively on your behalf before the NCIC.

We are ready and able to handle every aspect of your claim so that you can focus on your treatment and recovery.

Get Legal Help from Our Workers’ Compensation Attorneys in North Carolina

For 24 years, our firm has successfully represented injured workers throughout North Carolina, securing substantial benefits for clients facing complex workers’ compensation claims.

Our clients consistently praise our dedication and results. As Jon Connell shares: “Mr. Baznik handled my workers compensation case and stayed well ahead of it. Always keeping me informed and going the extra mile for my needs. I’m so glad I chose to call Joe Baznik and will use his team again if I ever need an attorney.”

Seeking a workers’ comp settlement after surgery can be intimidating and overwhelming, but working with our experienced team can give you the support and advocacy you deserve. Contact Younce, Vtipil, Baznik & Banks, P.A. online or call us at 919-661-9000 for a free consultation. Let our board-certified workers’ compensation attorneys help you pursue the benefits you deserve while you recover.

Does Surgery Increase a Workers’ Comp Settlement?