Can the insurance company refuse to pre-authorize surgery?


There’s been a recommendation for surgery.  The surgeon’s office calls the insurance company requesting it to pre-authorize the surgery so the surgeon knows he’s going to get paid.  Then the insurance company either flatly refuses to pre-authorize the surgery or doesn’t return the surgeon’s call.

So the employee can’t get the surgery and can’t go back to work because the doctor won’t release him to full duty.  Meanwhile, his employer has replaced him.

If the employee can get an adjuster on the phone, the adjuster tells him that the insurance company does not have a duty to pre-authorize medical treatment.  The adjuster suggests that the surgeon go ahead and perform the surgery and the insurance company might pay the bill afterwards knowing, of course, the surgeon won’t do that.  Or, the adjuster will suggest, the employee can pay for the surgery himself and ask for reimbursement.  Like, who has the money for that?

This situation is so common that over twenty years ago, the Supreme Court for the State of Alaska ruled an injured worker who has been receiving medical treatment should have the right to prospective determination of compensability.  Summers v Korobkin Construction, 814 P 2d 1369 (Alaska, 1991).

That means filing a claim.

It also means you can get an attorney.  The second thing the insurance company is trying to do, other than denying medical benefits, is preventing the injured employee from finding a lawyer to represent him.  When you call for an attorney, most lawyers will ask “Have you been controverted?”  That means have you received a formal Notice of Controversion (a document) from the insurance company.  If the answer is no, many attorneys aren’t interested in the case because, as a rule, the attorney cannot bet paid if the claim hasn’t been controverted.

But there are formal and informal controversions.  If the insurance company has resisted paying benefits, then its action constitutes a “controversion in fact” and justifies an award of fees.

If you hit a wall when you tell the person answering the attorney’s phone that the claim has not been controverted, call another attorney. Keenan Powell has more than 30 years experience fighting for the rights of injured Alaskans.

At the Law Office of Keenan Powell, you can get a free consultation by call 258-7663.