Doctor Recommends Surgery, but Work Comp Insurance Denies

Last Updated: 1/31/2024

Medical care denial commonly occurs in Iowa work injury cases because the employer chooses your providers for your injury case. The good news is that you can petition for alternative medical care, forcing the insurance company to pay for the recommended surgery. This requires proper procedures to be followed and documents filed, or the petition may be dismissed without a hearing and the medical care denied.

Should I fight to obtain medical care for my work injury on my own?

Receiving proper medical care in an Iowa workers comp claim can be difficult and frustrating. Injured workers have very little control over their medical providers and often medical care recommended by the insurance company doctors is delayed or denied.

While it is possible for an injured worker to successfully navigate the Iowa alternative medical care on their own, you will need to make sure you know the relevant law to be successful. You will want to read Iowa Code section 85.27 along with Rule 876 IAC 4.48 which describes the law and rules that apply to it. Also, several things to consider while doing it on your own:

1. Request medical recommendations

You will need to send a letter or email to the insurance adjuster to request to receive the recommended medical care. Failing to follow this step will likely result in your petition being dismissed.

2. Request a copy of the doctor’s notes recommending the surgery or other medical care.

3. Follow up on approval request

After a week or more, you will want to call the insurance adjuster to find out if your request for medical care has been approved. If approved, ask for a written authorization to be provided to your doctor’s office with a copy to you. Unfortunately, sometimes the insurance adjuster will tell you on the phone that it is being approved and never take the steps to approve the medical care.

4. Prepare a petition for Alternative Medical Care

If the medical care is not promptly approved the next step will be to prepare the petition for alternative medical care and attach your written evidence to the petition. You can find the Form 100C (14-0011, petition for alternative medical care) on the Iowa Workforce webpage.

The form is self-explanatory, but you will need to complete all required portions for the injured worker. You will then attach your medical records recommending the surgery and the email(s) and/or letter(s) that you sent requesting the medical care as evidence.

You will need to file the petition on the Iowa Workforce electronic filing system known as WCES which can be found at https://efile.iowaworkcomp.gov. You can request an account if you do not have one set up.

If you are not computer savvy you can request an exemption to file the petition in paper format. You will need to keep a copy of the petition and serve your employer by US mail certified return receipt requested. It is a good idea to send a courtesy copy to the insurance adjuster giving them notice that you have filed the petition. Sometimes once they see the petition on file they will go ahead and approve the medical care.

5. Prepare for a petition hearing

A hearing will be set in 10 to 14 days from when you file your petition. These hearings are almost always done by phone hearing with an administrative law judge.

The first issue will be for the judge to determine if the defendants are admitting your injury or if they decide to deny it.

Yes, they can decide to deny your claim at any time for any reason or no reason whatsoever.

Yes, they are supposed to have a medical opinion disputing your claim before they deny your claim, but insurance companies often wait to get this later.

If they decide to deny your case, then your petition will be dismissed, and you will not get a hearing. Your next step would be to file a petition for arbitration which will be a more formal hearing.

This could take 12 to 18 months before the hearing is set and another 3 to 18 months before an arbitration decision is entered and then possible appeals. If you have health insurance, Iowa law states that your health insurance pays for your medical care if the workers’ compensation insurance company has denied your claim.

6. Prepare for Formal Hearing

If the insurance company through their attorneys admits that your injury is work-related then you will be able to proceed with the hearing. The insurance company will likely have an attorney defending their case.

If you are not familiar with hearings this can be a problem for you. Keep in mind that you, the injured worker, have the burden of proof to show that the medical care being offered is not reasonable.

If the insurance company-authorized doctor has recommended surgery in writing and you have offered that into evidence as an exhibit, then usually this will be sufficient evidence that they are not offering reasonable medical care. A written decision (ruling on the petition for alternative medical care) will be entered usually 3 to 5 days after your hearing.

7. Appealing unfavorable decisions

If you or the defendants are not happy with the ruling on the petition for alternative medical care, each has the right to appeal by filing a petition for judicial review in the district court. This is an entirely different process that is a very similar process to filing a lawsuit in Iowa district court.

While this is an important step in the workers' comp process there are many other things to consider after sustaining a work injury. The defendants may want you to have an IME (independent medical examination) before agreeing to surgery or they may send you to another doctor for medical care. There are lots of things that can go wrong and you may want to consider getting some help.

Our team of injury attorneys handles medical care issues along with an injured worker’s case and does not charge extra for doing so. To find out if you have a good claim for alternative medical care and for answers to your other questions call our Iowa workers’ compensation team at 641-792-3595 or use our Live Chat feature by clicking here 24 hours a day/7 days per week or contact us online.

If one of our qualified workers’ compensation attorneys is not available, then you can schedule an appointment right away, so you have a set time and date to ask questions. There is no cost or obligation and your information will remain confidential. Also, please note that if you are receiving benefits and you decide to hire us then we will not take any portion of your ongoing weekly benefits, or any other benefits voluntarily paid by the insurance company.

If you are not ready to speak with an attorney but would like more information on the alternative medical care process (we have an entire chapter about it in our book) along with your rights and responsibilities, grab your copy of our Iowa Work Injury Book. We offer it at no cost because we have seen far too many Iowa workers make costly mistakes which resulted in the loss of thousands of dollars.

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