The appeals process varies by state, but is available any time a denial of coverage is made. In many states, for better or worse, both the employer and injured employee may appeal a denial of coverage.
Why Are Workers' Compensation Claims Denied?
There are a myriad of reasons why claims are denied, often varying by state, and thus a detailed list would be confusing and cumbersome. Below are the more common reasons workers' compensation claims are denied:
1) Timeliness – A common reason for denial is the claim was not filed quickly enough. Generally, an employee has to report an injury to their employer shortly after the injury was discovered, sometimes within a days after the incident.
2) Employer Dispute – After being injured, one of the worst scenarios is not having support from an employer. However, it is not uncommon for an employer to dispute a claim. When this occurs, the employer is typically saying that the injury:
- Did not happened at work
- Was not an accident
- Violated scope of employment or was illegal
- Occurred on the influence of drugs or alcohol
If an employer does contest an injury, and the insurance company sides with the employer, the claim will routinely be denied.
3) Not Covered – Although it is less common than the other two reasons for denial, it is possible for a claim not to be covered. For instances, the state’s insurance provider may not recognize the injury, the injury may be strictly preexisting, or may be too minor. If that is the case, a workers' compensation claim may be denied.
What Is the Appeals Process?
The process will vary depending on where the claim is filed. Generally, the very first thing someone who has had his or her claim denied should do is gather any and all relevant information. This may vary from the denial letter itself to doctor’s letters and co-workers' accounts of the event.
The next step involves actually filing the appeal. This can be incredibly detail intensive and require presenting additional documentation, ranging from co-worker statements to investigative reports and the expert opinion of medical experts.
Finally, the appeal will be scheduled, and the injured employee will have an opportunity to make their case.
Should I Hire a Lawyer?
Although it may be tempting to go through the process yourself, keep in mind that you have suffered enough already. It is no secret that the chances of a lawyer obtaining successful results is significantly higher than yours would be if you proceed alone, and if money is an issue, many worker’s compensation attorneys work on a contingency fee. Hiring an employment lawyer is one of the most sure fire ways to ensure you are treated fairly after your accident and help you get the recovery you are entitled to.