In a series of stunning decisions from the Alaska Supreme Court and the Alaska Workers Compensation Board, it was ruled that when an insurance company stalls authorization of an injured worker's surgery, the insurance company has violated the law.
These are the dirty tricks that the insurance companies will use to stall an injured worker's needed surgery:
1. They will claim they have no duty to preauthorize surgery. Not true. There is a duty to provide prompt medical treatment and to preauthorize needed surgery. In Bockus v First Student/ Sedwick CMS AWCB Decision No 14-00400 (3/24/14), the Board ruled that when the adjuster told the doctor that the account was "open and billable" but refused to specifically authorize the surgery, it was illegal.
2. They will claim they need an Employers Medical Evaluation (or "Independent Medical Evaluation") before they can authorize. Again, untrue. Although the insurance company has the right to demand an EME, it is not bound to do so. Bockus.
3. They will claim they need to send a letter to the doctor for clarification and cannot authorize the surgery until the doctor responds. Again, not true. In Kamitchis v Swan Employer/Liberty Mutual, AWCB Decision No 14-0039 (3/24/14), the Alaska Workers Compensation Board ruled that when Liberty Mutual adjuster Sam Moore failed to promptly authorize surgery, his actions were illegal. In that case, Liberty Mutual said would not specifically authorize the surgery until the doctor responded to a letter Mr. Moore had sent him.
Under these cases, it is clear that the insurance company must tell the doctor that they will pay for the recommended surgery (preauthorize) and if they don't, they must have a legally recognizable reason and they must controvert within 30 days of the surgical recommendation.
So what do you do if the insurance company is stalling your surgery? You call an attorney and get a claim filed. The Board can order the insurance company to pay for the surgery, award you money penalties against the insurance and order the insurance company to pay your attorneys fees.
Keenan Powell has practiced Workers Compensation law in the State of Alaska for more than 30 years and has dedicated her practice to Workers Compensation representing injured Alaskans.
All consultations are free. If you want to set up a meeting, use the contact form on www.keenanpowell.com or call: 907 258 7663.