Denied Workers’ Comp for Rotator Cuff Surgery. What Now?


Lisa Allen

A reader wrote in with this question: “I hurt my shoulder at work and my doctor says I need rotator cuff surgery. However, I tried to file a workers’ comp claim and my employer denied it because I didn’t see their authorized provider. Is that legal? What should I do next?”

First, we’re so sorry to hear about your injury as it must be painful and stressful to deal with. Shoulder injuries can cause significant pain that lasts far longer than anticipated, even if it’s not a torn rotator cuff. Each case depends on the person and a variety of factors, including:

  • Type of accident that caused the injury
  • Type of work the injured person does
  • The injured person’s age

Here’s what you should do next, dear reader: Hire a workers’ compensation lawyer to file your appeal. Otherwise, you may have to pay for rotator cuff surgery out of your own pocket.

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Does Every State Have Authorized Providers for Workers’ Comp Injuries?

State law, not your employer, dictates which doctors can treat injured workers after an on-the-job accident. The one exception is if you are a federal employee, in which case there’s a separate set of parameters.

Other factors that matter include how large your employer is and whether you’re a contractor, seasonal worker, or full-time employee.

If you live in one of the following states, you may see any doctor you choose to treat a workplace injury:

  • Alaska
  • Connecticut
  • Delaware
  • Hawaii
  • Illinois
  • Kansas
  • Louisiana
  • Maryland
  • Massachusetts
  • Mississippi
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New York
  • North Dakota
  • Ohio
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Dakota
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
  • Washington, D.C.

In the following states, your employer chooses which doctor you see for your workplace injury:

  • Arizona
  • Florida
  • Georgia
  • Kentucky
  • Texas
  • Virginia

Each state’s laws are different. So, it’s important to understand how your specific state’s laws work before you seek rotator cuff surgery or other treatment. When in doubt, you can always consult a local workers’ comp lawyer for free about your claim.

What Happens If I Wait to Have Rotator Cuff Surgery?

Rotator cuff surgery can be daunting due to how expensive and time-consuming it takes to recover. You might think that delaying surgery could give you enough time to save up for this expense. But that’s not necessarily true. Until you can undergo rotator cuff surgery, you still need medical treatment to continue living without terrible pain and discomfort.

Even if you simply choose to take time off work to rest, it will likely cost you some lost wages. Choosing physical therapy is also somewhat expensive, especially if your employer’s insurance policy won’t cover it. Initial appointments typically range from $150 to $300, and ongoing appointments can cost anywhere from $75 to $150 per hour. Of course, your own health insurance may cover some of this cost, depending on your policy.

For example: Your plan may have you pay out-of-pocket for physical therapy until you meet your annual deductible. It’s not unusual to need ongoing physical therapy appointments lasting anywhere from 3-6 months. All of this adds up and can become quite costly. Perhaps the most important consideration is that the longer you wait for rotator cuff surgery, the more expensive and less effective it may be. Plus, you’ll incur more costs trying to manage your injury and pain until you can have surgery.

How An Attorney Help You Get Workers’ Comp to Cover Rotator Cuff Surgery

If your state allows injured workers to choose their own physician, your workers’ comp attorney can immediately appeal your denial. This may be the fastest way to get your rotator cuff surgery covered under workers’ compensation.

But what about if you live in a state that requires your employer to choose the doctor for you? In that case, an attorney can help determine if your company followed the appropriate rules based on your state’s laws. A lawyer can help you determine the best way to secure compensation for your rotator cuff surgery costs as well as pain and suffering, if appropriate.

One thing you want to be sure of, though. Don’t hire an attorney who promises you a big settlement unless they’ve heard all the details of your case. Every case is different. An attorney needs to understand your situation and your state’s laws in order to give you the right legal advice.

Ready to see if you might qualify for a free, no-obligation consultation from a nearby workers’ compensation attorney? Click the button below now to get started:

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Lisa Allen

Lisa Allen is a writer and editor who lives in suburban Kansas City. She holds MFAs in Creative Nonfiction and Poetry, both from the Solstice Low-Residency Program in Creative Writing at Pine Manor College. Prior to becoming a writer, Lisa worked as a paralegal, where she specialized in real estate in and around Chicago.