Workers Compensation Appeal Process

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 What Is Workers’ Compensation?

Workers’ compensation laws are a body of laws that provide financial and medical benefits to sick or injured workers. Although what is covered varies by state, typically the following are included:

  • Medical bills;
  • Missed income; and
  • Rehabilitation costs.

The program is primarily supported by employer-paid insurance premiums. It is designed to create a no-fault system in which workers are able to obtain compensation without having to establish that their employer was at fault for their sickness or accident.

Workers’ compensation is provided to offer employees a safety net while also reducing the number of lawsuits that are filed against employers for occupational illnesses or injuries.

What Are Workers’ Compensation Attorneys?

Worker’s compensation attorneys represent employees who are injured on the job and who are seeking benefits using the workers’ compensation system. An attorney may assist the employee throughout the complex legal process, which may include submitting a claim, appealing a refused claim, and negotiating a settlement.

An attorney may also represent the employee in court if the issue goes to trial. An attorney can also assist employers with compliance and defending against lawsuits.

What Benefits Are Available under Workers’ Compensation?

Typically, workers’ compensation laws provide the following workers’ compensation benefits:

  • Medical expenditures: An employee is entitled to reimbursement for medical expenses they incurred because of a job-related accident or sickness, including:
    • doctor appointments;
    • hospital stays;
    • medicines; and
    • physical therapy;
  • Lost pay: An employee is usually entitled to a portion of their lost pay when they cannot work due to an accident or sickness. The quantity and length of pay replacement benefits varies from state to state;
  • Permanent disability benefits: If an employee becomes permanently handicapped because of a job-related accident or disease, they may be eligible for compensation for their loss of earning capability;
  • Vocational training: Some states will provide vocational rehabilitation benefits, including employment training or education, to assist an injured employee in returning to work; and
  • Death benefits: The dependents of an employee may be eligible for death benefits if the employee dies due to a job-related accident or sickness.

It is important to note that the amounts and benefits that are granted vary by state. Some states may provide more benefits than others.

What Are the Requirements of Receiving Workers’ Compensation?

The qualifications for collecting workers’ compensation payments varies by state. However, usually, an employee is required to fulfill the following criteria:

  • The worker must have been hurt or become unwell because of their employment. The worker’s injury or sickness must have happened while executing their job tasks or as a consequence of the working environment;
  • The worker must have disclosed the accident or sickness to their employer within a specific time, generally a few days to a few weeks;
  • The workers’ accident or sickness must have resulted in medical care; and
  • The worker must have made a workers’ compensation claim with the proper state agency or insurance company.

It is important to note that, in certain areas, a worker may be required to establish that their job was the cause of their sickness or injury. If the worker’s employer or insurance company contests their claim, the worker may be required to present proof to back up their claim.

The conditions for receiving workers’ compensation payments differ across states and the procedure may be complex. If an individual has any questions about the process, they should consult with a workers’ compensation lawyer.

It is important to note that there may be workers compensation statute of limitations, or time limits, on filing claims and appeals.

What Is a Workers’ Compensation Appeal?

A workers’ compensation appeal is the process whereby an injured employee who has been denied workers’ compensation benefits can request reconsideration or to make a case about why their injury or illness should be covered. The appeals process is different in every state.

However, an appeal is available any time a denial of coverage is made. In the majority of states, both the injured employee and the employer can appeal a denial of coverage.

Why Are Workers’ Compensation Claims Denied?

There are numerous different reasons why workers’ compensation claims are denied, which typically vary by state. Because of this, it would be difficult to create an entire list.

The following are common reasons that workers’ compensation claims are denied:

  • Timeliness: One common reason for denial is the claim was not filed quickly enough;
    • In general, an employee has to report an injury to their employer shortly after the injury was discovered, sometimes within days after the incident;
  • Employer dispute: After being injured, one of the worst scenarios is not having support from an employer. It is not uncommon, however, for an employer to dispute a claim. If the employer contests an injury and the insurance company sides with them, the claim will usually be denied. When this happens, an employer is typically saying that the injury:
    • Did not happened at work;
    • Was not an accident;
    • Violated scope of employment or was illegal; or
    • Occurred on the influence of drugs or alcohol;
  • Not covered: Although it is less common than the previous two reasons for denial, it is possible for a claim not to be covered. For example, the state’s insurance provider may not recognize the injury, the injury may be strictly preexisting, or may be too minor. If these situations apply, a workers’ compensation claim may be denied.

Can I Be Fired for Filing a Worker’s Compensation Claim?

Employers are not allowed to terminate employees for filing workers compensation claims. If this occurs, it is a retaliatory dismissal or wrongful termination.

If an employee believes they were terminated in retaliation for submitting a workers’ compensation claim, they have a right to file a complaint with the proper state government or to sue their employer.

What Is the Appeals Process?

The workers’ compensation appeals process will vary depending on where the claim is filed. In general, the first step an individual should take when they have had their claim denied is to gather any related relevant information.

This can include anything from the denial letter itself to doctor’s letters or a co-worker’s account of the events that occurred. The next step is to actually file the appeal.

Filing a workers’ compensation appeal can be very detail intensive and require presenting additional documentation, which may include:

  • Co-worker statements;
  • Investigative reports; and
  • The expert opinion of medical experts.

After this, the appeal will be scheduled and the injured employee will be able to present their case. In many cases, a workers’ compensation lawyer will handle this type of case on a contingency fee basis, meaning the individual only pays if they win.

Should I Hire a Lawyer?

If your workers’ compensation claim has been denied and you want to file an appeal, it is important to consult with a workers’ compensation lawyer. It may be tempting to try and go through the process yourself but it can be very difficult if you are already injured or sick.

In addition, your chances of success greatly increase when you are represented by an attorney. Having an attorney on your case is one of the best ways you can ensure you are treated fairly following your accident or injury and you are able to obtain the compensation you deserve.


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