What If My Doctor Recommends Surgery But the Insurance Company Says It's Not Necessary?

You may have seen in this profile that the insurance company doesn't always go according to the recommendation of your treating physician. In fact, in E.P.'s story you can see that he had to have two surgeries because the first one resulted in a serious condition called "frozen shoulder" and he struggled to get the second surgery authorized.

If the insurance company is refusing to authorize the recommendation of your treating physician, you should call an attorney. Often times the insurance company will hire their own doctor to examine you, who is paid by them and will most of the time find in favor of them.  They call this exam an Independent Medical Examination, or IME.

We call it what it really is - an Insurance Medical Exam.  You're not there for medical treatment and the doctor has no duty to you (most won't even talk to you - they'll say you just have to get the report from the workers' comp insurance company). 

Sometimes the only way to get your treatment authorized is through filing for an informal conference (mediation) or a formal hearing. The informal conference is non-binding but might help to reconcile the differences between the two sides. If that doesn't work or for more serious adjudication issues, a formal hearing will result is a binding decision from an adjudication judge. 

At Donahoe Kearney we use all of the process to your advantage: to pressure the insurance company to do the right thing, or have a judge order them to do the right thing.  

There are no insurance company tactics, strategies, or tricks that we haven't seen (and we can see them coming and prepare you for them). We will do everything we can to make sure your treatment is authorized and that you are on the road to healing. 



If you have been caught up in an IME battle or the workers' comp adjuster is denying or delaying your medical treatment after a serious work injury, give us a call at 202-393-3320 or email us at [email protected]. You'll speak to a real person today: no obligation and completely confidential