Having surgery after a work-related injury can increase your workers’ compensation settlement. However, there are some things you need to know so you receive the best benefits available. While workers’ comp will still pay for whatever treatment you need, the timing of the surgery will determine how it’s covered and the amount of your settlement. 

Workers’ Compensation Insurance Defined

As a quick reminder, California requires employers to provide workers’ compensation insurance coverage for all employees, with few exceptions. This insurance provides disability benefits such as partial wages for the time you are unable to work. Worker’s comp also pays for your medical expenses. In the event of your death, survivor benefits are paid to your family.

Your progress is monitored by doctors who report to the insurance company. When your physician determines that you have reached your Maximum Medical improvement (MMI), the insurance company will issue a disability rating that is used to calculate any disability benefits.

Disability benefits can be classified as temporary or permanent, depending on how your ability to work is affected. You may be eligible for permanent disability benefits, which can be awarded as either partial or total disability. 

How Much Can Surgery Increase My Settlement?

Depending on the type of surgery and the injury it addresses, the amount will range from a few thousand to hundreds of thousands of dollars. Unfortunately, no one can give you a specific amount without hearing the circumstances you face. There are so many factors that will affect the surgery and, therefore, the amount of settlement.

As a guideline, surgeries involving the spine or joints can be more expensive and have a more difficult recovery. Injuries involving the back and limbs often affect your ability to work more severely, and an experienced workers’ comp lawyer will understand how to negotiate a fair amount.

Again, it’s important to consider after-surgery costs and recovery expenses so that you have what you need for full health. This can ensure you reach a sufficient settlement and aren’t left facing bills you can’t pay.

Before or After a Settlement? Timing is Everything

Whether to have a recommended surgery before or after settlement will depend on many different factors. Generally, if you have access to other insurance to pay for your surgery you are better off settling your case and have your surgery done outside of workers compensation. With that said below are some of the issues to consider.

It’s crucial to consider the pros and cons of settling before you have surgery:

Pros of settling:

  • With an accurate estimate of the projected amount for the surgery and all associated costs, you can negotiate a larger settlement payment.
  • You can use the surgeon you want and have the surgery when it fits your schedule. You won’t need to get authorization from the insurance company.
  • You don’t need to worry about workers’ comp denying the claim or pursuing litigation to get the payments you need.
  • It might be possible that your personal insurance or Medi Cal will pay for the surgery.

Cons of settling:

  • You will pay out-of-pocket for the procedure, but you will have the settlement money to help with the expenses.
  • You might suffer repercussions from the surgery that could affect your work. If you’ve already settled, you will not be able to go back to the insurance company and claim medical benefits. 
  • You could be left paying for any complications if you hadn’t planned for them. These could end up costing more than you received in your settlement.

If you have the surgery after the settlement is completed you would not be able to claim additional permanent disability if there were complications. It can be difficult to understand what is best for your circumstances, and working with a skilled workers’ compensation attorney can alleviate some of the confusion. 

California Provides Two Ways to Settle a Workers’ Comp Claim Quickly

Settling can be attractive if you want control of your health decisions instead of relying on company-approved doctors. California has two methods of closing your claim quickly, but each has specific conditions you should consider.

Compromise and Release

In this option, you and your employer agree to a lump-sum payment from workers’ comp that includes a specific dollar amount for permanent disability, any outstanding temporary disability payments, plus a sum to cover any future treatments.  This leaves you free to pursue your choice of medical providers.

However, it also means the case is closed permanently, and you cannot reopen it if your health deteriorates. Using this method to settle a claim could be disastrous if you need surgery after the claim is closed. You should negotiate for potential coverage of costs such as:

  • Future medical bills, including any additional surgery
  • Potential expenses for post-surgical complications
  • Other indirect costs, such as lost wages, physical therapy, or an extended hospital stay
  • Benefits if you become permanently disabled as a result of the surgery

Stipulation with Request for Award

If you would like to settle but have the option to reopen your claim if your condition worsens, this path gives you that choice. You and your employer agree to a permanent disability payment but leave the medical benefits open to be paid for by the workers’ comp insurance. 

You would receive biweekly payments until the total is paid and can reopen your claim within five years if your condition deteriorates and you need surgery or other extensive treatment.

Deciding if Surgery is Necessary

If your doctor recommends surgery, then your workers’ comp benefits will cover it if you have not settled your claim. However, keep in mind that the physicians used by insurance companies are encouraged to try conservative methods first, such as occupational and physical therapy, and pain medicines. If your surgery is truly necessary, the delay could worsen your condition by making you wait.

The decision to have surgery should be made with your health as the number one priority. If the surgery leads to a full recovery from the injury with no pain or impairment, you will regain your health but may face a lower settlement. It is not a good idea to have surgery just to try to drive up the settlement amount. 

There are numerous risks to going under the knife, even if you are otherwise healthy. And, if you choose to have surgery that the attending physician did not recommend, the insurance company may refuse to pay for it, leaving you stuck with the bill.

As you can see there are a lot of factors to consider concerning whether or not to have a surgery. In some cases the decision will be based upon what type of settlement monies are offered by the insurance company. The only way to really know if their offer is fair and makes sense is to discuss your options with a workers compensation attorney.