Does Surgery Increase Workers’ Comp Settlements?

If you have an injury resulting from an incident at work, you may qualify for workers’ compensation benefits. But what happens if your injury is serious enough to require surgical intervention? Does surgery increase workers’ comp settlements?

The short answer is yes, surgery typically increases workers’ comp settlements. This is due to the increase in medical expenses and the often lengthier recovery periods associated with surgeries.

However, very specific caveats exist regarding the increase to your workers’ comp settlement. These include but are not limited to:

• Type of surgery
• Timing when the surgery takes place
• Location
• Results of the surgery
• Claim status

Read on to make sure you know how these parameters can decrease or increase workers’ comp settlements after surgery.

When Will a Surgery Increase Workers’ Comp Settlements?

If your surgery takes place before the final settlement, workers’ comp will cover the cost as a medical expense.

As such, surgery expenses will not be part of a total settlement claim. The insurance company will consider the surgical fees a past medical expense if workers’ comp initially pays for the procedure.

So, in this instance the claimant won’t be able to recover extra money for the costs of the actual operation. Unless, of course, they are due some reimbursement for out-of-pocket expenses associated with the surgery.

Settlement offers that happen prior to a surgery—or the recommendation that one is necessary—will invariably be lower. In this case, it’s important for the claimant to not settle too quickly and not end up with enough to cover impending expenses.

That’s why it’s wise to speak to a workers’ comp attorney before accepting any proposed settlement. A lawyer who is familiar with these types of cases can evaluate if an offer is too low.

Surgical costs and hospital stays can be incredibly expensive. The injured worker may be anxious to settle a claim, but end up lacking funds to cover future medical expenses.

Surgery increases workers’ comp settlements if the claimant still needs the procedure. That’s because the settlement agreement would have to cover the costs of the surgery, as well as related medical expenses like:

• Hospital stays/nursing care
• Diagnostic tests
• Anesthesia
• Prescription medications
• Wheelchairs, crutches, canes, braces, prosthetics
• Physical therapy
• Occupational therapy

How Will Your Workers’ Comp Settlement Be Awarded?

It’s important to understand the two types of workers’ comp awards that injured workers may receive as settlement offers. That’s because the type of settlement you accept will also affect your ability to get future care, including surgery.

The two main settlement options for workers’ comp claims are:

1. Stipulation and Award Settlements
2. Compromise and Release Settlements

Stipulation and Award Settlements

With a stipulation and award settlement, the workers’ compensation insurance company commits to paying for all future medical treatments. Of course, this only covers medical treatments associated with your workplace injury. But it’s an ongoing agreement with the insurer that will last for the rest of their life.

While that sounds like the obvious way to go, sometimes it is difficult to get insurers to hold up their end of the bargain. So, if you accept this type of award, you’ll also want to define how and when they’ll make payments.

In other words, if you need another surgery, clarify in advance that the bills will go to the insurance. And make sure there isn’t any fine print that could preclude them from paying your expenses.

Compromise and Release Settlements

A compromise and release settlement is the more common offer in most workers’ comp cases.

In this type of settlement, the workers’ comp insurance company will offer the claimant a lump sum. This payment is to cover all future care relating to your work-related injury.

The risk of a compromise and release settlement is that you’re unable to reopen the case once you settle. If you accept a compromise and release settlement and then discover you need further surgery, it may not cover your expenses. But you will not have much recourse to get more.

Therefore, before accepting such an offer, it’s once again important to consult with a workers’ comp attorney.

What Factors Go Into a Workers’ Comp Settlement with Surgery?

Obviously, the type of award you’ll receive will affect if surgery increases your workers’ comp settlement. But so too does the timing.

If the surgery takes place before settling a claim, the payout may increase regardless of which type of settlement. Similarly, if surgery occurs after a stipulation and award settlement, the insurance company must still cover the expense.

However, if a surgery is to happen after accepting a compromise and release settlement, then a claimant must consider:

• Future medical care expenses
• Costs of any post-surgical complications
• Post-surgery rehabilitation
• Future disability benefits and lost wages

All of these must factor into the settlement. That’s because once an injured worker accepts an offer, they won’t be privy to future payouts.

Other factors that determine if surgery increases workers’ comp settlements include the type, success rates, future costs, and surgical multiplicity.

Type of Surgery

Some surgeries are inherently more expensive than others. For example, a surgery to pin a broken finger will be much less than a traumatic brain injury.

Accordingly, the type of surgery a work-related injury needs will also affect how much surgery increases workers’ comp settlements.

Your location may also influence the cost of a surgical procedure. There is no national standard of what a hospital charges for a particular surgery. The same procedure may be thousands of dollars more predicated on where the surgery happens.

For example, the average per-day hospital cost in the U.S. is $2,883. California clocks in at the highest ($4,181), with Mississippi costing the least ($1,305). But wherever you are, you can see how expenses may quickly add up.

Odds of Success

While it may seem counterintuitive, the higher the likelihood of a surgery’s success, the lower the settlement.

That’s because some surgeries result in a 100% recovery, meaning the employee will likely return to work. Other surgeries may result in permanent work restrictions even when they are successful, which may cost more in disability payments.

A workers’ comp insurance company will keep these surgical odds of success in mind when determining a settlement offer.

Future Costs and Losses

Insurance companies consider future costs when looking at how a surgery will affect a claimant and their prognosis. If a surgery requires extensive recovery, then the workers’ comp claim must include those future costs in their calculations.

The category also includes future losses. For example, if the surgery results in some degree of permanent ability loss, that will be a factor. The type of work someone participates in will be another factor determining future costs/losses.

In other words, a professional dancer undergoing hip replacement surgery may experience a greater loss than someone with a desk job. This does not exclude 

Multiple Surgeries

The need for multiple surgeries will likely increase an individual’s workers’ comp claim.

If a surgery restores some or all lost function from an injury, an injured worker may find their settlement finalized. However, if an injury requires multiple surgeries, it’s probable the worker will be left with a permanent disability, increasing their workers’ comp settlement value.

In cases where the need for future surgeries seems likely, it’s extremely important to have a well negotiated settlement.

Do I Need Approval For My Surgery?

When dealing with a workers’ comp case, you will absolutely need to obtain approval for a surgery. Otherwise, your insurance company may argue against the expense.

However, securing approval for surgery for a workers’ comp claim can be a complicated process. At the very least, an injured worker will need a doctor to provide an opinion stating that surgery is necessary. Sometimes, however, a claimant will need to involve a lawyer to ensure that they get the surgery that they need.

If you’ve already made an agreement for a compromise and release settlement, you will be out of luck. So be very clear about any potential surgeries you may need in the future before accepting this type of payout. Otherwise, you may not have the funds to cover the medical procedures you need if your condition further deteriorates.

Talk to an Attorney to Protect Your Workers’ Comp Settlement

Though in general surgery increases workers’ comp settlements, every case is unique. Many factors come into consideration, including the injury severity, type of required surgery, the worker’s job, and the recovery projections.

Also, don’t forget that your employer retains the workers’ comp insurance company. As such, even though they’re covering your bills, their goal is to keep their costs down. Accordingly, some insurance companies may argue that surgery is unnecessary or too expensive, to reduce your settlement.

That’s why it’s vitally important that anyone facing surgery while trying to recover from a work-related injury seek representation. An experienced workers’ compensation attorney can help an injured worker negotiate more effectively, and advocate for a fair settlement.

Don’t try to navigate the emotional and physical repercussions of a workplace injury by yourself. Let us connect you with a skilled workers’ comp attorney so your settlement will sustain you through surgery and beyond.