If you’ve been injured on the job in California and need surgery, you may be wondering: Does workers’ compensation cover surgery? The short answer is yes. However, securing approval for surgery through workers’ compensation can be a complex and time-consuming process. At Laguna Law Firm, our experienced workers’ compensation attorneys help injured workers navigate the claims process and fight for the medical care they need, including necessary surgical procedures.
Does Workers’ Comp Cover Surgery in California?
Yes, California workers’ compensation laws require employers to cover medical treatment, including surgery, for employees who suffer job-related injuries or illnesses. The state’s workers’ compensation system operates under a no-fault policy, meaning you do not have to prove your employer was negligent—only that your injury occurred while performing work-related duties.
Under California Labor Code Section 4600, your employer’s insurance must provide medical treatment that is “reasonably required to cure or relieve the effects of the injury.” This includes:
- Emergency surgery for severe workplace injuries
- Elective or planned surgeries for chronic or worsening conditions
- Orthopedic procedures such as spinal surgery, knee replacement, or carpal tunnel surgery
- Reconstructive surgery if necessary for recovery
However, just because surgery is covered doesn’t mean the approval process is simple. Insurance companies frequently delay or deny surgical requests, which is where an experienced workers’ compensation lawyer can make all the difference.
What Types of Workplace Injuries May Require Surgery?
Certain workplace injuries commonly require surgical intervention. Some of the most frequent injuries that qualify for workers’ comp surgery in California include:
- Back and Spine Injuries – Herniated discs, spinal fractures, or nerve damage often require surgical treatment.
- Knee Injuries – Torn ACLs, meniscus tears, or chronic knee pain from repetitive strain.
- Shoulder Injuries – Rotator cuff tears or dislocated shoulders that fail to heal with physical therapy.
- Hand and Wrist Injuries – Carpal tunnel syndrome, tendon injuries, or fractures requiring surgical repair.
- Traumatic Injuries – Broken bones, deep lacerations, or internal injuries caused by workplace accidents.
If your doctor recommends surgery to recover from a work-related injury, you should immediately consult a workers’ compensation attorney to ensure your rights are protected and that your claim is not unfairly denied.
How Do You Get Surgery Approved Through Workers’ Comp?
1. Obtain a Medical Evaluation
To receive workers’ comp benefits, you must first be evaluated by a doctor within your employer’s Medical Provider Network (MPN) unless you predesignated your personal doctor before your injury.
2. Submit a Request for Authorization (RFA)
If your doctor determines that surgery is necessary, they will submit an RFA to the insurance company for approval.
3. Utilization Review (UR) Process
The insurance company will then conduct a Utilization Review (UR) to determine if the procedure is “medically necessary.” Unfortunately, many surgical requests are denied at this stage.
4. Appeal a Denied Surgery Request
If your surgery is denied, you have the right to appeal through the Independent Medical Review (IMR) process. Having a skilled workers’ compensation lawyer from Laguna Law Firm can significantly improve your chances of success.
What If Your Surgery Is Denied?
Insurance companies often deny or delay surgeries to save money. Common reasons for denial include:
- Claiming the surgery is “not medically necessary”
- Arguing that alternative treatments, such as physical therapy, should be tried first
- Disputing whether the injury is work-related
If your surgery is denied, do not give up. Our attorneys at Laguna Law Firm specialize in fighting denied claims and will appeal the decision to ensure you get the medical treatment you deserve.
Can You Get a Workers’ Comp Settlement for Surgery?
Yes, in some cases, injured workers opt for a workers’ compensation settlement that includes funds for surgery. There are two types of settlements:
- Stipulated Findings and Award – Keeps medical benefits open for future treatment, including surgery.
- Compromise and Release (C&R) – Provides a lump-sum settlement, but you waive your right to future medical care.
Choosing the right settlement option is critical, and our workers’ compensation lawyers will help you make the best decision based on your needs.
How a Workers’ Comp Lawyer Can Help You Get Surgery
Getting surgery approved through workers’ comp can be frustrating. The insurance company may try to stall or deny your claim, leaving you in pain and unable to work. At Laguna Law Firm, we fight for injured workers by:
- Ensuring your medical records support your need for surgery
- Challenging any wrongful denials or delays
- Representing you in appeals and Independent Medical Reviews
- Negotiating a fair settlement if appropriate
Don’t let the insurance company control your recovery. Our experienced workers’ compensation attorneys will fight for your right to receive the medical care and financial support you need.
Contact Laguna Law Firm Today
If you need surgery after a workplace injury, don’t face the complex workers’ compensation system alone. Let Laguna Law Firm handle the legal battle so you can focus on healing. Call us today at (949) 594-2090 or visit lagunalawfirm.com to schedule a free consultation.
Your recovery matters. Let us fight for the benefits you deserve!
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