- | By Steele & Ferguson, P.C.
If workers’ compensation denied your surgery in Michigan, do not assume the insurance company has the final say. If the surgery is reasonable, necessary, and related to your workplace injury, Michigan workers’ compensation may be responsible for paying for it—and you may be able to challenge the denial. If your doctor says you need surgery but workers’ comp will not approve it, get the denial in writing, keep treating with your doctor, preserve your medical evidence, do not settle your claim prematurely, and speak with an experienced Michigan workers’ compensation lawyer immediately. Michigan law requires employers to provide reasonable medical, surgical, and hospital services when they are needed because of a work-related injury.
Call Steele Law now at 248-704-2542 for a free consultation. Don’t wait. Waiting hurts your case.
What Should I Do If Workers’ Comp Denied My Surgery in Michigan?
Take these steps immediately:
- Find out exactly why the surgery was denied.
- Get a copy of the denial in writing.
- Ask your surgeon to clearly document why surgery is necessary.
- Make sure your doctor explains how the condition is related to your work injury.
- Keep copies of MRIs, X-rays, CT scans and medical reports.
- Continue attending medical appointments.
- Follow your doctor’s restrictions.
- Request a copy of any Independent Medical Examination report.
- Do not agree to a workers’ comp settlement without understanding what happens to your future surgery.
- Speak with a Michigan workers’ compensation attorney about challenging the denial.
A surgery denial is not necessarily the end of your claim.
It means there is now a dispute over medical treatment—and that dispute may need to be fought.
Does Michigan Workers’ Comp Have to Pay for Surgery?
Michigan workers’ compensation generally requires an employer or its insurance carrier to provide reasonable and necessary medical treatment related to a compensable workplace injury.
Michigan’s Workers’ Disability Compensation Act specifically includes reasonable:
- Medical treatment
- Surgical services
- Hospital services
- Medication
- Other necessary treatment
Medical care can continue for as long as it is reasonable, necessary, and related to the workplace injury.
That can include major procedures such as:
- Back surgery
- Spinal fusion
- Neck surgery
- Rotator cuff surgery
- Shoulder surgery
- Knee surgery
- ACL or meniscus surgery
- Carpal tunnel surgery
- Hand or wrist surgery
- Foot or ankle surgery
- Surgery following a fracture
- Surgery for nerve damage
The central issue usually becomes:
Is the surgery medically necessary, and is the need for surgery related to the work injury?
That is where many insurance disputes begin.
Why Would Workers’ Comp Deny Surgery?
Workers’ compensation insurers may challenge surgery for many different reasons.
Common arguments include:
- The surgery is not medically necessary.
- Your injury did not happen at work.
- Your current symptoms come from a pre-existing condition.
- Your MRI does not justify surgery.
- Conservative treatment has not been exhausted.
- The insurance company’s doctor says surgery is unnecessary.
- You can return to work without surgery.
- Your condition is degenerative rather than work-related.
- The insurer claims your work injury only temporarily aggravated your condition.
- The insurance company disputes the entire workers’ compensation claim.
One of the most common problems occurs when your treating surgeon recommends surgery but an insurance-company doctor disagrees.
That can put your medical treatment, workers’ comp checks and ability to return to work at risk at the same time.
What If the Workers’ Comp IME Doctor Says I Do Not Need Surgery?
Take that report seriously.
An Independent Medical Examination, or IME, is often requested when an insurance company wants another medical opinion about your injury.
The IME doctor may conclude:
- You do not need surgery.
- Your condition is pre-existing.
- Your injury has healed.
- You can return to work.
- Additional treatment is unnecessary.
- Your symptoms are unrelated to your job.
- You have reached maximum medical improvement.
When an IME doctor and your personal physician disagree, you have the right to continue following your own physician’s advice, although the employer or insurer may act based upon its IME opinion and benefits can become disputed.
If an IME is being used to deny your operation, read Steele Law’s guide to what happens at a workers’ comp Independent Medical Exam in Michigan.
Can I Challenge a Workers’ Comp Surgery Denial in Michigan?
Yes.
A disputed workers’ compensation medical claim can potentially be brought before the Michigan Workers’ Disability Compensation Agency.
Formal disputes are commonly started by filing Form WC-104A, Application for Mediation or Hearing.
Depending on the case, the dispute may involve mediation, a pretrial proceeding, negotiations or a hearing before a workers’ compensation magistrate.
Evidence may include:
- Your surgeon’s medical opinion
- MRI or CT scan findings
- Operative recommendations
- Treatment records
- Physical therapy records
- Prior medical records
- Work restrictions
- Specialist reports
- IME reports
- Evidence explaining how your job caused or aggravated the condition
If your claim has become disputed, also read What Happens If My Workers’ Comp Claim Is Denied in Michigan?.
What If Workers’ Comp Says My Injury Was Pre-Existing?
A prior medical condition does not automatically mean the insurance company wins.
This issue frequently arises with:
- Degenerative disc disease
- Previous back problems
- Arthritis
- Prior knee injuries
- Shoulder problems
- Previous surgeries
- Neck degeneration
- Carpal tunnel symptoms
- Old sports injuries
The important medical and legal question may be whether your work caused, contributed to, aggravated or accelerated the condition in a manner recognized under Michigan workers’ compensation law.
That often requires strong medical evidence.
Do not simply accept the statement:
“You already had that problem before you got hurt at work.”
A pre-existing condition can make a case more complicated, but it does not automatically eliminate a valid workers’ compensation claim.
What If My Surgery Keeps Getting Delayed Instead of Officially Denied?
A delay can become just as serious as a denial.
You may repeatedly hear:
- “We need more medical records.”
- “It is under review.”
- “We need another opinion.”
- “The adjuster hasn’t approved it yet.”
- “We are waiting for the IME.”
- “Authorization is still pending.”
Meanwhile, you may remain in pain and unable to work.
Medical benefits should be provided beginning with the work injury and that reasonable and necessary medical treatment is part of the workers’ compensation system.
Do not allow an indefinite delay to become the insurance company’s answer.
Find out whether the treatment is actually being denied and what legal options exist to move the case forward.
Can I Choose My Own Surgeon in Michigan?
Michigan has an important 28-day rule.
During the first 28 days of medical treatment, the employer generally has the right to select the treating physician.
After 28 days, an injured worker may select another physician after notifying the employer and insurance company of the change and providing the physician’s name.
Read Steele Law’s full guide: Can I Choose My Own Doctor for Workers’ Comp in Michigan?.
Changing doctors, however, does not automatically resolve an existing dispute about whether surgery is work-related or medically necessary.
Should I Settle My Michigan Workers’ Comp Case Before Surgery?
Be extremely careful about settling before a recommended surgery is resolved.
Surgery can affect:
- Future medical expenses
- Time away from work
- Wage-loss benefits
- Physical therapy
- Medication
- Permanent work restrictions
- Future earning capacity
- Additional procedures
- Overall settlement value
For example, suppose an insurance company offers a settlement while a surgeon is recommending spinal surgery.
Accepting a settlement without accurately accounting for the surgery, recovery period and future medical needs could potentially leave you responsible for major expenses later.
The bigger the medical issue, the more important it is to understand exactly what rights you are giving up.
What If Workers’ Comp Stops My Checks After Surgery Is Recommended?
This is another major warning sign.
Sometimes the sequence looks like this:
- Your treating doctor recommends surgery.
- The insurance company schedules an IME.
- The IME doctor says you do not need surgery.
- The IME doctor says you can return to work.
- Surgery is denied.
- Wage-loss checks are stopped or disputed.
Now both your medical treatment and income may be at risk.
Read Can Workers’ Comp Stop My Benefits in Michigan?.
Do not assume that because checks stopped, the insurance carrier has legally proven that you are no longer entitled to benefits.
What Medical Evidence Can Help Fight a Surgery Denial?
Strong medical documentation can be critical.
Helpful evidence may include:
- MRI findings
- X-rays
- CT scans
- EMG or nerve testing
- Specialist evaluations
- Surgical recommendations
- Failed physical therapy
- Failed injections
- Failed medication treatment
- Work restrictions
- Medical opinions connecting the condition to your job
- Records showing worsening symptoms
- A detailed response from your treating doctor to the IME physician
Ask your surgeon to be specific.
A statement that simply says “patient needs surgery” may be less useful than a detailed opinion explaining:
- The diagnosis
- Objective findings
- Why conservative treatment failed
- Why surgery is medically necessary
- How the work injury caused or aggravated the condition
- What could happen without surgery
- Expected recovery
- Future restrictions
Common Michigan Work Injuries That Lead to Surgery Disputes
Surgery-denial cases frequently involve serious injuries suffered by:
- Construction workers
- Factory employees
- Auto workers
- Warehouse employees
- Truck drivers
- Delivery drivers
- Healthcare workers
- Machine operators
- Skilled trades workers
- Maintenance employees
- Municipal workers
- Retail employees
Common injuries include:
- Herniated discs
- Rotator cuff tears
- Torn meniscus
- ACL injuries
- Spinal injuries
- Nerve injuries
- Crush injuries
- Serious fractures
- Shoulder tears
- Knee injuries
- Neck injuries
If surgery is on the table, this is no longer a minor workers’ compensation claim.
Frequently Asked Questions About Workers’ Comp Surgery Denials in Michigan
Can workers’ comp refuse to pay for surgery in Michigan?
An insurance carrier can dispute a surgery, but that does not automatically mean the denial is correct. Michigan law requires reasonable and necessary medical and surgical treatment for compensable work injuries. A disputed denial may be challenged through the workers’ compensation system.
What if my doctor says I need surgery but workers’ comp says no?
Get your doctor’s recommendation and the insurance company’s denial in writing. Preserve diagnostic records, continue following legitimate medical advice, obtain any IME report and speak with a Michigan workers’ compensation attorney about challenging the denial.
Can an IME doctor stop my surgery?
An IME physician does not personally cancel an operation, but the employer or insurer may rely on that doctor’s opinion to dispute payment for the surgery or other benefits.
Can I request a copy of my Michigan workers’ comp IME report?
Yes. An injured worker may make a written request to the insurance carrier and should receive a complete and correct copy of the IME report within 15 days of the request.
Do I need a lawyer if workers’ comp denied surgery?
You are not legally required to hire an attorney, but a surgery denial means there is now a significant dispute involving medical evidence and potentially substantial benefits. Speaking with an experienced Michigan workers’ compensation lawyer can help you understand how to challenge the insurer’s position.
Can I file for a hearing over denied medical treatment?
Michigan workers can use the Workers’ Disability Compensation Agency dispute process when benefits or medical care are contested. Form WC-104A is the employee’s Application for Mediation or Hearing.
What happens if I cannot work while waiting for surgery?
You may have a claim for workers’ compensation wage-loss benefits if your compensable work injury prevents you from working and the legal requirements are met. If an IME doctor says you can return to work while your surgeon says you cannot, the case can become disputed.
Does workers’ comp pay for physical therapy after surgery?
Reasonable and necessary medical care related to a compensable work injury can include rehabilitation and other post-surgical treatment. Michigan law also provides for medical and vocational rehabilitation in qualifying cases.
Workers’ Comp Denied Your Surgery in Michigan? Call Steele Law Now
Your doctor says you need surgery.
The insurance company says no.
That does not mean the fight is over.
A denied operation can affect your health, your ability to work, your income and the future value of your workers’ compensation case.
Steele Law represents injured workers throughout Michigan in disputed workers’ compensation cases involving denied medical treatment, surgery, IMEs, stopped benefits, serious workplace injuries and insurance-company disputes.
If workers’ comp denied your back surgery, neck surgery, shoulder surgery, knee surgery or another procedure after a Michigan workplace injury, get answers now.
Call Steele Law at 248-704-2542 for a free consultation.
Don’t wait. Waiting hurts your case.
