Does surgery increase a workers’ compensation settlement?

Posted on May 12, 2022

Surgery can increase the workers’ compensation settlement, but usually only if the surgery is to happen after the settlement agreement. If it happens before the agreement, and the surgery is necessary to treat a work-related injury, then the insurance company will generally cover it as a part of your medical expenses.

Depending on the surgery needed, the settlement amount can increase by tens of thousands of dollars or more.

Will my settlement increase if I get a surgery before settling the case?

Not necessarily. If you get surgery to treat a medical condition that stemmed from a workplace accident or occupational disease, and the surgery happens while the case is still pending, it will be paid for by the workers’ compensation insurer.

It will fall under the medical benefits that you are entitled to receive under workers’ compensation law. However, anticipated complications from the surgery that happens after the settlement may increase the settlement amount.

After a workplace injury, you will generally have to go to a treating physician that has been chosen by your employer or your employer’s workers’ comp insurer. These doctors are often chosen precisely because they treat patients conservatively. This reduces the medical expenses that the insurer will have to pay for your care.

That conservative treatment focuses on low-cost care, first. It usually entails:

• occupational therapy,
• physical therapy, and
• pain medication.

Only if these treatments fail will the employer’s doctor try more expensive options, including surgery.

If your workers’ comp claim has not been settled before the surgery happens, then the costs of the surgery will generally be covered by the workers’ comp insurance company. It is a part of the medical benefits that they provide to injured workers.

However, the costs of the surgery are not strictly confined to the procedure, itself. Surgeries can create additional medical expenses and conditions, such as:

• the costs of a longer hospital stay,
• wages lost while recovering from the surgical procedure,
• physical therapy to recover from the surgery, rather than the underlying medical condition that required the procedure,
• costs of anesthesiology during the surgery,
• costs of pain relievers in the aftermath of the surgery,
• follow-up visits to make sure the procedure worked, and
• costs of any complications or setbacks from the procedure.

If you incur these losses before your workers’ comp claim has settled, they should be covered as medical or disability benefits. If your case has been settled, these additional costs should be reflected in the settlement amount. A workers’ compensation attorney can negotiate on your behalf, or can file a personal injury claim if there are grounds to file one.

Will my workers’ comp settlement increase if I need surgery in the future?

Yes, if you are settling your workers’ comp claim for a lump sum and still need surgery, the settlement amount should reflect the costs of that upcoming procedure. This should increase your workers’ comp settlement amount.

Depending on the type of procedure and the likelihood of complications, it can increase your settlement amount substantially.

There are 2 ways to settle a workers’ compensation claim:

1. stipulation and award, or
2. compromise and release.

Under a stipulation and award agreement, the workers’ comp insurance company agrees to cover all future medical care you need for the injury for the rest of your life.

Under a compromise and release, the insurer hands you a lump sum to cover all of the future workers’ comp benefits you are entitled to receive. This type of settlement offer can be in a lump sum payment all at once, or in a structured settlement where the payout is stretched over a period of time.

When most people think of a workers’ comp settlement, they think of a compromise and release.

If your settlement agreement is for a compromise and release, the settlement amount should include:

• costs of future medical care, including any upcoming surgeries,
• anticipated costs of any complications from those surgeries,
• indirect costs of those procedures, like a prolonged hospital stay, lost wages during recovery, and physical therapy, and
• future permanent disability benefits.

The insurer will go to great lengths to minimize the settlement amount. An adjuster from the workers’ comp insurance carrier will downplay the severity of the surgery and its risks. By establishing an attorney-client relationship with a workers’ compensation lawyer from a reputable law firm, you can get the legal advice you need to maximize your settlement value and cover your future medical expenses.

By how much can surgery increase my injury settlement?

It will depend on the surgery and the type of injury it corrects. The costs of the surgery and the expenses that it will indirectly cause should be included in the settlement amount. More expensive surgical procedures should increase your settlement amount by more than minor surgeries.

Additionally, where you get the surgery can influence its cost. Identical procedures can be more expensive in one state than in another.

The medical bills for some common surgical procedures to correct work-related injuries are:

• spinal fusion procedures for serious back injuries – $110,000,
• joint replacement surgeries – $16,500 to $33,000, and
• surgeries to fix a broken wrist – $8,000.¹

The indirect costs of a surgical procedure should also increase your settlement amount. Some examples are:

• non-surgical hospital costs – $2,607 per day, and
• overnight hospital stay – $11,700 per night.²

Depending on the surgery and the body parts that it covers, then, the average workers’ comp case can increase by tens or even hundreds of thousands of dollars. Hiring a workers’ comp lawyer can ensure that you get what you deserve in these workers’ compensation cases.

What types of workers’ compensation can I receive?

Generally, there are 2 different types of workers’ compensation benefits that you are entitled to receive after a workplace injury:

1. disability benefits, and
2. medical expenses.

If the injury was a fatal one, the victim’s spouse or loved ones may be entitled to death benefits. In some states, these are called survivor benefits.

You also may be entitled to recover your workers’ comp attorney’s fees.

Disability benefits

Disability benefits aim to compensate you for the wages you have lost and stand to lose due to the injuries you have sustained. There are temporary disability benefits and permanent disability benefits.

Temporary disability benefits cover your wage loss while you recovered from the workplace accident.

Permanent disability benefits cover the wages you will likely lose in the future because of your impairment or debilitation.

You generally receive temporary disability benefits until you reach maximum medical improvement (MMI). This is the point at which further medical care will not improve your condition. Medical professionals will then determine the extent of your disability. Your disability rating will then be used to calculate permanent disability benefits.

Both of these types of benefits can be either:

• total, or
• partial.

Total disability means that you cannot work in any capacity. Partial disability means that you can only work in a reduced or restricted role.

For example: Mark is a landscaper making $20 per hour. He breaks his leg while on the job and needs surgery. He spends 5 days in the hospital recovering. His doctor then clears him for light duty doing office work. He returns to his employer’s office in a cast and answers phones. However, this role only pays $15 per hour. Mark was totally disabled for the 5 days he spent in the hospital. He is only partially disabled while he answers phones in the office.

The amount of disability benefits will depend on the state’s workers’ compensation laws. They are generally 2/3rds (two-thirds) of your lost weekly wages from before the accident.

Medical expenses

You are also entitled to workers’ compensation for any of your medical expenses related to the workplace injury. Before settling, these are paid for by your employers’ workers’ compensation insurer. If you took a lump sum settlement, you will be responsible for paying for any future medical treatment you need.

Also, see our related page on Can I still get disability after a workers’ comp settlement?

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