Workers Compensation Denial

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 What Is Workers Compensation?

Workers’ compensation is a state-mandated insurance program, providing compensation to employees who suffer injuries while on the job. An employee who is injured while on the job is guaranteed workers compensation benefits, regardless of who was at fault.

However, in return for workers’ compensation benefits, employees generally forfeit their right to sue their employer in court for damages for their injuries. In this way, the rules which govern workers’ compensation are considerably different than the rules for most other personal injury matters.

In general, workers’ compensation benefits include:

  • Replacement income;
  • Medical expenses reimbursement;
  • Rehabilitation expenses;
  • Long-term or lump sum pension, if you are permanently unable to work because of the injury; and
  • Temporary disability pension while you are unable to work due to the injury.

In order to satisfy workers’ compensation requirements, you must be an actual employee of your employer. What this means is that you cannot be an independent contractor. Additionally, your injuries must be work related, and your employer must actually be covered by workers compensation insurance.

There are several steps that you must follow in order to receive workers’ compensation. You must:

  • Promptly report your injury to your employer, as some states require notice within 2-30 days following the injury. If an injury or illness results over time, you must report it as soon as you become aware that the injury or illness was caused by your work;
  • Obtain medical treatment and follow your doctor’s instructions;
  • File your claim with your employer’s insurance carrier. It is important to note that your employer must provide insurance claim forms; and
  • Save all copies of paperwork throughout the filing process.

What Does Workers Compensation Cover, And What Does It Not Cover?

Workers’ compensation is intended to provide benefits to injured workers, regardless of whether the injury was the employer’s fault or the employee’s fault. What this means is that as long as your injury is work-related, it is covered under workers’ compensation.

Some examples of typical injuries that are covered by workers compensation include:

  • Repetitive stress injuries;
  • Illnesses or diseases that are a gradual result of work conditions;
  • Traumatic physical injuries;
  • Repeated trauma injuries;
  • Mental injuries, when they are associated with physical injury; and
  • Various occupational diseases.

As you can see, workers’ compensation provides for nearly every type of injury that may occur at the workplace. However, there are several types of injuries which remain uncovered, including:

  • Self- inflicted injuries, which includes injuries sustained when you cause a fight;
  • Injuries resulting from the commission of a serious crime;
  • Injuries caused by your conduct, when it violates company policy;
  • Injuries received while intoxicated or under the influence of illegal drugs; and
  • Injuries sustained as the result of you, as an employee, acting in a reckless manner.

Additionally, several classes of workers are not entitled to receive workers’ compensation benefits. The following are examples of employees who are not covered by workers’ compensation:

  • Business owners;
  • Independent contractors;
  • Federal employees, under the state’s scheme;
  • Domestic employees in private homes;
  • Farm workers;
    Maritime workers;
  • Railroad employees; and
  • Unpaid volunteers.

It is important to note that workers compensation laws can vary considerably by state. An example of this would be how California workers compensation laws generally differ from those in other states, such as Texas.

Why Was My Workers Compensation Claim Denied?

A workers compensation claim may be denied for any number of reasons. However, if your initial claim is denied, the workers compensation claim process allows you to appeal the denial through the state board of workers’ compensation. When a workers compensation claim is denied, it generally means that the claims administrator believes that your injury is not covered by workers’ compensation.

If the claims administrator sends you a letter detailing the reason for your denial, you have a right to challenge the decision. However, it is important to note that there are time limits on when you can appeal the decision; as such, moving forward with the appeal in a timely fashion is essential.

To reiterate, there may be a variety of reasons as to why a workers’ compensation claim would be denied. Some examples of the most common reasons for denial include:

  1. The claim was not filed on time, as most state laws require claims to be reported within 30 to 90 days after the injury;
  2. The injury was not reported on time, as most state laws require the injury to be reported to the supervisor within a couple of days after the injury has occurred;
  3. The employer disputes the claim, and is successful in the dispute;
  4. No medical treatment is actually needed. You must generally receive medical treatment in order to receive workers compensation benefits;
  5. Your injury is not severe enough for a claim;
  6. Your injury is part of a pre-existing condition; and/or
  7. You filed a claim after you were laid off, or the injury was not during your employment.
  8. Essentially, if the claim is not due to workplace injury and/or exposure, your claim for worker’s compensation will be rejected.

Can I Appeal My Workers Compensation Denial?

You should first contact your employer or your employer’s workers’ compensation insurance brokers in order to discuss your claim denial.

To initiate an appeal, you must gather information for both your employer and the claims investigator. The denial letter that was sent to you should contain information on the deadline for filing your appeal, as in many states, there is a specific amount of time in which you can file your appeal. Additionally, it is essential to refrain from saying anything contradictory or incorrect, such as that it gives the insurance company more reason to deny your claim.

After you have gathered all of the necessary information, you should:

  1. Review your denial letter carefully;
  2. Consider contacting your employer in order to discuss your claim;
  3. Schedule an administrative law hearing to present your case, and within the prescribed time period;
  4. Gather all relevant medical records and evidence for your hearing; and
  5. Attend the appeal hearing.

At the appeal hearing, you must present medical and other factual evidence in order to support your workers’ compensation claim, which you will present to the judge. The judge will then evaluate the evidence and the claim as a whole in order to determine how reliable and credible the evidence is to support your claim.

Most workers compensation hearings last a few hours; however, they can take a couple of days if the case is especially complicated. It is important to note that the judge will not make a decision at the hearing, but will review all the evidence presented, and will write and send a decision to you within 30 to 90 days.

At your appeal hearing, you and the insurance company will both give the judge a variety of documents and evidence for the judge to review, as was previously mentioned. This may include:

  • Past medical records;
  • Evidence of your lost wages while injured;
  • Unpaid medical bills from your injuries;
  • Documents showing your subsequent job search; and
  • Depositions and reports made by expert witnesses, such as your doctor.

Do I Need A Lawyer For Help With A Workers Compensation Denial?

Though you may attend the appeal hearing by yourself, you may consider using workers compensation lawyers.

Your lawyer can help you understand your legal rights and options according to your state’s specific laws, and can help you gather all relevant evidence in order to support your case. Additionally, an attorney will also be able to represent you in court, as needed, throughout the process.


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