Q: Workers comp specific: Trying to understand how a claim works if I have ACL surgery scheduled tomorrow before approval
I’m an Art Director who also organizes the company party’s & functions. It was the end of our holiday function, I was cleaning, an intoxicated coworker waiting on a sober ride who was wearing 3 inch heals took a tumble using me to stop her fall she pivoted us in a spin to the ground with her weight on top of me. My knee madw a loud pop. I had ACL surgery on the same knee 01/2016. it had finally healed. This happened on the 12/8, I put a brace on it the next morning, came back to clean up the party & meet rental vendors. Monday it was worse so I tried to get an appt. Booked with the holidays... so I email my surgeon (my neighbor) that weekend and got him to squeeze me in. After the MRI I found out I have to have surgery. It is scheduled for 1/4. After discussing it with others I was urged to make a claim. When I went to ask my doctor’s office to send all my medical records & now they say they will have to process it another way and my primary insurance will have nothing to do with it?
A: There are several issues presented in your facts. You need to report your injury to your employer. You should have your surgeon get the surgery preauthorized under workers compensation even if you have the surgery on your private health. You should submit the claim to the workers' comp carrier and have them deny the claim first before proceeding with the surgery if you can wait. They will likely deny the claim stating it is a preexisting injury because you already had surgery on it previous. You will, therefore, need to get a radiologist and/or surgeon to compare your MRI reports and/or films to show that you actually sustained new damage or harm to your knee. I think you do well to consult a workers' comp attorney of your choice. I wouldn't be able to explain everything to you in this short answer.
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