May 30, 2020

Does Workers’ Compensation Cover Total Knee Replacement?

Knee injuries are very common workplace injuries. According to the Bureau of Labor Statistics, about 100,000 Americans sustain on-the-job knee injuries every year. For many, these are serious, debilitating injuries. The road to recovery can be long and difficult, often requiring extensive treatment and knee surgeries.

If you are eligible for workers’ compensation in Georgia, your knee injury will be covered by workers’ comp as long as it resulted from your work-related duties. This includes all “reasonable and necessary” medical treatments, which could include surgeries, such as total knee replacement surgery. However, workers’ compensation insurance providers often try to dispute these claims or limit the amount they have to pay out for treatment by questioning whether surgery is truly “reasonable and necessary.”

When Is Medical Treatment “Reasonable & Necessary?”

The “reasonable and necessary” phrasing is important, as it is one of the key elements in determining whether your total knee replacement surgery will be covered by workers’ compensation. So, when is knee surgery considered “reasonable and necessary” for the purposes of workers’ compensation?

Typically, when your physician determines that you need surgery, including total knee replacement, it is considered reasonable and necessary to your recovery. However, your employer or their insurance company may request that you undergo an independent medical evaluation, or IME. The purpose of an IME, ostensibly, is to determine whether an injury is truly work-related and/or if the recommended treatment is truly reasonable and necessary. However, it’s important to note that IME doctors often favor employers—these examinations are rarely as “independent” as they seem.

Injured employees are also permitted by Georgia workers’ compensation laws to request a second opinion and receive an IME from a physician of their choice. You must follow a certain timeline—120 days of the last receipt of benefits—in order to request an IME with a doctor you choose.

What If the Insurance Company Is Saying I Had a Pre-Existing Condition?

Often, insurance companies will claim that an injured employee had a pre-existing condition as a way of denying claims. However, a pre-existing knee injury does not mean that you cannot receive workers’ compensation benefits. If you can show that your knee injury was caused by or aggravated by your work or work-related duties, you can still file a claim for workers’ compensation benefits.

It’s important that you work with an experienced and knowledgeable attorney, as complications with your workers’ compensation claim can be challenging to overcome without the help of a legal professional.

Will I Have to Pay for Any Part of My Knee Replacement Surgery?

If you are eligible for workers’ compensation under Georgia workers’ compensation law, no, you will not have to pay for any portion of the knee replacement surgery as long as it is considered a reasonable and necessary treatment. Georgia workers’ compensation includes medical benefits, which cover the full cost of all medical expenses related to your work injury. This includes everything from initial emergency room visits to diagnostic services to surgery to rehabilitation, prescription medications, medical equipment and devices, and more.

You should also be entitled to receive temporary disability benefits while you recover and are unable to return to work or perform light duty work. TD benefits in Georgia are equal to two thirds your average weekly wage subject to a state-imposed maximum, which changes each year.

For more information, contact Hansford McDaniel LLC for a free consultation with one of our workers’ compensation lawyers.