About 3 years before she needed us, our client got hurt at work when she slipped on gravel at a basketball court at the Charles Lea Center in Spartanburg. She tore a right knee ligament, her ACL. The employer’s workers’ compensation insurance company paid for her initial treatment. After she developed problems with her left knee caused by her right knee work injury, the insurance company refused to provide treatment. She came to Rob, who filed for a hearing before a Workers’ Compensation Commissioner to get treatment. Before the hearing, Rob convinced the insurance company to treat the left knee.
This case shows how aggressive workers’ compensation insurance companies can be in denying injured workers treatment to inflate the insurance company’s bottom line. Several months later, the insurance company again denied treatment by refusing to pay for an operation recommended by the surgeon, who the insurance company selected. The insurance company claimed it shouldn’t pay because Medicare deemed the surgery experimental. Rob requested another hearing.
At the hearing, Rob presented evidence to a Workers’ Compensation Commissioner showing why the surgeon recommended the operation, including: the surgery was not experimental, as the surgeon had performed over 50 of the procedures with good results, the only other option was a partial replacement, which would lead to a full knee replacement at too early an age, the denied procedure would delay a total knee replacement for a decade or more, and it gave our client a better chance of regaining and preserving mobility.
At the hearing, the insurance company likely revealed the true reason for its denial when it argued the procedure just cost too much. Rob overcame the insurance company arguments with not only evidence, but the law. He pointed out the overriding purpose of the Workers Compensation system is to reduce disability and achieve relief or a cure for work injuries. There is no “Medicare-calls-it-experimental” exception. The law does not allow an employer or insurance company to dictate medical treatment.
The Commissioner concluded denying the recommended surgery could potentially increase and prolong disability by forcing our client into a knee replacement too early. She ordered the insurance company to provide it.
This case also shows how devastating some work injuries can be. As a result of her work accident, our client had 7 knee surgeries in 6 years. We ultimately settled her case for a clincher of $49,156.30, representing essentially the rest of the money benefits she could get under workers’ compensation. But most importantly, the insurance company agreed to pay all future medical care for both knees, which is especially vital since the surgeon virtually assured her she’ll likely need at least one of them replaced.