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What You Need to Know About Denied Workers’ Comp Claims

If you sustain an injury on the job, state laws allow for you to receive workers’ compensation benefits. The primary intention of these benefits is to pay you back for some of the wages that you cannot earn due to your injury and the medical bills that you have incurred. While this is not the full amount of your paycheck, these benefits are a relief for families struggling with the loss of income that a breadwinner provides, as well as any medical treatment needed.

Not Every Workers’ Compensation Claim Is Approved

While filing a workers’ compensation claim is far from a formality, many claims are approved and benefits issued. However, as too many people know firsthand, the claims process is not this simple for many people. In some situations, the workers’ compensation insurance company will partially or completely deny a valid claim.

Because there is a chance that an insurer could deny your initial claim, it is important to know what to do in this situation. Too many injured workers might assume that a denial is the end of the road and they have no chance of obtaining benefits. This is a mistake, as an initial denial does not mean that you will never receive benefits. It does mean, however, that you will need to work harder to receive them.

If you find yourself facing a workers’ compensation denial, seek help from the best workers’ compensation lawyer near you as soon as possible.

Why Employers May Try to Fight Your Workers’ Compensation Claim

The system gives the company the incentive to contest your workers’ compensation claim. In many respects, workers’ compensation insurance is just like any other type of insurance. The more claims in need of payment against a company, the more insurers will charge a company for workers’ compensation insurance premiums. In other words, even if your employer is not paying your claim directly, receiving benefits raises their cost of doing business.

Some companies simply do not care that accidents happen in the workplace. Instead, they focus first on their bottom line at the expense of their employees. You would think that companies would value the workers’ compensation system as a way of protecting them from direct negligence lawsuits.

However, they may fight your claim for the following reasons that have little to do with the merit of your case:

  • Workers’ compensation claims could harm the company’s reputation because others may then view the company as an unsafe place to work.
  • The company may want to make an example out of you to discourage other people from filing claims.
  • Your employer has the lawyers on staff and does it just because they can. However, claims that are initially denied and then later paid might result in much higher costs for the company.
  • They think that they can scare you out of fighting back, and you will simply give up rather than taking your case to the next level.
  • The insurance company also has its own interests, and these businesses do not make profits by writing checks to claimants.

Common Reasons Why Workers’ Compensation Claims Are Denied

To understand your legal rights and the best course of action following a denial, it is critical to understand the reasons the insurance company gave for your denial.

The reasons for denials to workers’ compensation include:

  • There was not a work-related injury – One major requirement is that the injury must have happened during the scope of your employment. In other words, you must have been on the job when it occurred. If you were on your way to work, on break, or doing something that was not part of your job, it might not be a covered injury.
  • There was no injury – The basis for a workers’ compensation claim is that you suffered an injury in the workplace. The employer or their insurance company may say that either you were not hurt or that the injury was not serious enough to require any treatment or time off work. Different states have varying rules concerning the recognition of certain injuries.
  • The employee had a preexisting condition – If this is the case, then the insurer might try to deny your claim. However, this does not automatically disqualify from receiving benefits. If your job worsened your condition then you should qualify to receive workers’ compensation for the additional treatment you needed.
  • No individual reported the accident promptly – Each state has its own legal timeline for when some must report an injury to their employer. Usually, it is between ten and 90 days. If you miss this deadline, you could lose the right to compensation.
  • The employee was under the influence – If alcohol or drugs were a factor in the workplace accident, then the employee may be responsible for their own accident, and they do not qualify for workers’ compensation benefits.

These are just some reasons behind a claim’s denial. If your initial answer was a no, you must receive the reason why.

Note that the employee’s negligence should never be a reason for denial. Unless the employee engaged in intentional misconduct or was intoxicated, their actions do not usually factor into the decision to award the benefits. If the employee’s negligence is the basis of the claim’s denial, they already have solid grounds for an appeal. Workers’ compensation is a no-fault coverage that does not try to figure out who was responsible for the injury.

Insurance company denials do not always stem from facts. For example, an insurer might claim that your injury happened away from work, but you know that your injuries resulted from work-related events.

Hire a Workers’ Compensation Lawyer

It is always best to seek a workers’ compensation attorney from the start of the claim. Having a lawyer on your side will help minimize some of the hassles that can slow down or imperil your claim. The attorney will help you with the paperwork and documentation for your claim to avoid some of the simple mistakes that can lead to a denial. Your lawyer can ensure that you put the best foot forward with your initial application for benefits.

If you are without legal counsel and receive a notice of denial for your claim, there may be very tight timelines for a possible appeal. You need to start immediately and do not have any time to waste trying to figure out the appeal process or your grounds for contesting your denial. A workers’ compensation lawyer can begin work on your appeal immediately. The stakes are too high not to have a professional on your side.

A Lawyer Can Help You Understand the Reason for Your Denial

As discussed above, there are different reasons for workers’ compensation denials. Some may be because of a technicality or some errors in the paperwork. Perhaps the applicant did not include all the required documentation. It may be a case of just filling out the claim paperwork wrong.

Some workers’ compensation disputes may simply result from a misunderstanding between the employee and employer. Your attorney can speak with the insurance carrier or your employer to find out their issue with your application. In some cases, your attorney can clear up the problem with a simple conversation, and get your claim approved.

You should immediately seek to understand the reason for the denial. If it seems like you will need to file an appeal, time is of the essence. If you have not yet hired an attorney, now would be the time to do so because you do not have any time to spare.

Filing a Workers’ Compensation Appeal

The good news is that the insurance company and your employer do not have the final say about whether you receive benefits. There is a process that can go above and beyond an insurer to determine whether you deserve benefits.

Each state will have different rules about how you can appeal your workers’ compensation denial. Know that in every state, there is a compressed timeframe to file your appeal. Deadlines are usually between 30 and 90 days after you receive the denial, but they can be sooner in some states. The law tries to protect companies by keeping them from having to answer appeals filed many months down the line. The appeal deadlines are strict. If you cannot file in time, you may permanently waive your right to receive any workers’ compensation.

The exact process that your case follows depends on the state in which you live. States will have their own judicial-type bodies that hear workers’ compensation appeals. In some states, you will end up in front of an administrative law judge specializing in these cases.

How Your Workers’ Compensation Appeal Process Begins

The appeal would begin with your filing a legal document explaining the reasons behind your claim’s improper denial. You would need to put the basis of your appeal in writing. You will need to show that the insurance company made a mistake or used incorrect reasoning.

Once you file the appeal, you will usually have your day in court at a hearing in front of a judge or a hearing board. This is where you would present testimony and evidence that showed that the insurance company was wrong.

If the reason for denial centered on the nature of your injury, you could present testimony from a medical professional about your condition. In addition, the judge could review the medical records to draw his or her own conclusion. You may even testify yourself. If the insurance company or your employer is contesting your appeal, they may have their own witnesses. Your attorney would get a chance to cross-examine them. As you can see, a workers’ compensation appeal is similar to any other court hearing.

The Burden of Proof Is on You in an Appeal

At an appeal, you need to show the judge why you need and deserve workers’ compensation benefits. As the claimant, the burden of proof would be on you to show that you meet all the criteria to receive benefits. You must have sufficient evidence to support your claim and the mistake of the insurance company.

After hearing all evidence from both sides, the judge should issue a ruling in your case. The length of this process depends on the state in which you reside, and usually, the appeals process is complete within six months, with most cases resolved more quickly. States recognize that both the employer and employee have an interest in resolving appeals quickly.

If a judge denies your workers’ compensation appeal, your lawyer can advise you of your next options. In each state, at least some court above the administrative judge or appeals board will hear your case. In many cases, this would now mean that you are going into the state court system.

The Right Workers’ Compensation Attorney Can Help

Personal Injury lawyer

Workers’ Compensation Lawyer, David Brauns

While receiving a claim denial can seem devastating, you should take comfort in knowing that denial is not the end of your fight for workers’ compensation benefits. An experienced workers’ compensation lawyer in your area will know the steps to take to appeal your denial.

This might include:

  • Determining the reason for the denial
  • Negotiating with the insurance company directly
  • Gathering additional evidence of your eligibility for benefits
  • Representing you in all communications and proceedings

Never let an initial denial deter your fight for benefits that you deserve after a work-related injury. Insurance companies can reverse their decision, or an administrative law judge or appeals board might find in your favor. In either situation, you can begin receiving coverage of your medical treatment and lost wages.

You do not have to face your workers’ compensation appeal on your own. Let a workers’ compensation attorney fight for you and tell you what you need to know about your specific situation. Contact Brauns Law, PC today.

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