A workers compensation claim may be denied for any number of reasons. If your initial claim is denied, you should not give up hope. The workers compensation claim process allows you to appeal the denial through the state board’s of workers’ compensation. When a workers compensation claim is denied, it means that the claims administrator believes your injury is not covered by workers’ compensation.
If the claims administrator sends you a letter that details the reason for your denial you have a right to challenge the decision. There are time limits on when you can appeal the decision, so moving forward with the appeal in a timely fashion is crucial.
Why are Workers Compensation Denied?
A workers compensation claim may be denied for a variety of reasons and once an applicant gets denied, they need to determine the reason why they were denied so they can remedy the denial. When an claim gets denied, the reasons for the denial will be explained in the denial letter sent to the applicant.
There may be a variety of reasons of why a workers’ compensation claim would be denied:
- The Claim was not Filed on Time: Most state laws require claims to be reported within 30 to 90 days after the injury
- Injury was not Reported on Time: Most state laws require the injury to be reported to the supervisor within couple days after the injury has occurred.
- Employer Disputes the Claim: Your employer disputes the claim and is successful in the dispute.
- No Medical Treatment is Needed: In many situations, you must receive medical treatment to receive workers compensation benefits. .
- Not a Severe Enough Injury: Your injury is not severe enough for a claim.
- Pre-Existing Condition Exists: Your injury is part of a pre-existing condition.
- You filed a claim after you were laid off or injury was not during your employment
- Essentially, if the claim is not due to workplace injury/exposure, then your claim for worker’s compensation will be rejected.
What is the Process to Appeal My Denial?
The first step to consider is to contact your employer or your employer’s workers’ compensation insurance brokers to discuss your claim denial.
To initiate an appeal, you must carefully gather information for your employer and the claims investigator. The denial letter that was sent to you should have information on the deadline for filing your appeal. In many states, there is a certain time limit that you can file your appeal. It is essential to not say anything contradictory or wrong such that it gives the insurance company more reason to deny your claim.
After you have all of the necessary information, you should:
- Review your denial letter carefully;
- Consider contacting your employer to discuss your claim;
- Schedule an administrative law hearing to present your case, and within the prescribed time period;
- Gather all relevant medical records and evidence for your hearing; and
- Attend the appeal hearing.
What Happens in the Appeal Hearing?
At the appeal hearing, you will be required to present medical and other factual evidence to support your workers’ compensation claim. At the hearing you will present all of the evidence to the judge. The judge will then evaluate the evidence and the claim overall and see how reliable and credible the evidence is to support your claim.
Most workers compensation hearings last a few hours, but can be a couple of days if the case is complicated. The judge will not make a decision at the hearing, but will review all the evidence presented to him and will write and send a decision to you within 30 to 90 days.
What Documents and Evidence Should I Present at the Appeal Hearing?
At your appeal hearing, you and the insurance company will give the judge a variety of documents and evidence for the judge to review. This may include:
- Past medical records;
- Evidence of your lost wages while injured;
- Unpaid medical bills from your injuries;
- Documents showing your job search; and
- Depositions and reports by expert witnesses such as from your doctor.
Do I Need a Lawyer?
Though you may attend the hearing by yourself, many people opt to use employment lawyers. The attorneys are well versed in the law, and less likely to be tricked by the insurance company’s attorneys. Overall, an attorney may be able to get your case resolved quickly, and in your favor with better results than that you can achieve by yourself.