What To Do If Your Workers’ Comp Claim Gets Denied?
Suffering injuries at work can leave you unable to earn a living for days, weeks, months, or even permanently. You’re in pain and can’t work and have thousands of dollars of medical bills. Fortunately, workers’ compensation is available in every state for most employees. You can receive medical bills and partial lost income benefits if your case is approved. But what if your workers’ comp claim gets denied?
Discover more in this post about what you can do if your claim faces denial. Talk to a workers’ comp attorney today if you have specific questions about your case or want to file an appeal. Remember that every state has different workers’ compensation laws, so the rules that apply to your case can vary considerably. Your Crawfordsville workers’ compensation attorney will be familiar with your state’s laws and will ensure that your case adheres to the statutes and goes smoothly.
What Is Workers’ Compensation?
Every state has a workers’ compensation system that provides medical and income benefits to injured employees. Most states require the coverage and cover most employees, but there are some exceptions, depending on state law. For example, the workers’ comp system does not usually cover contractors. Some states also exempt seasonal and farm workers. However, the state’s workers’ compensation system typically applies to most workers.
Workers’ compensation benefits are available on a no-fault basis. This means you do not often have to prove fault to receive benefits. If the accident occurred on the job or during your employment, you probably qualify if you are a company employee.
For instance, if you fall down the stairs at work and are an employee, you can receive medical benefits and partial income during your recovery. Another example is if you are attending a work conference downtown and slip on the hotel lobby floor and break your ankle, you also should receive benefits. But, if you were driving home after the conference was over and suffered an injury in a car accident, this will not be covered by workers’ compensation. If you have questions about whether a job-related injury is covered, talk to a workers’ comp attorney today at no cost.
Some common covered job-related injuries include:
- Spine and spinal cord injuries
- Joint and shoulder injuries
- Back and neck injuries
- Traumatic brain injuries and concussions
- Carpal tunnel syndrome
- Repetitive motion injuries
- Hearing loss
- Vision loss
- Chronic pain conditions
- Paralysis
- Lung and respiratory injuries from toxic chemicals
- Burns
- Catastrophic injuries
- Amputation
Types Of Workers’ Compensation Benefits
You can receive workers’ compensation benefits in many ways based on the severity and duration of the injury. First, if the injury happened at work, you are entitled to all reasonable medical treatments for your recovery or until you reach maximum medical improvement (MMI).
Second, a workplace injury may prevent you from working temporarily or permanently. Workers’ comp will provide a portion of your lost earnings if you suffered an injury. Many injured parties receive temporary partial disability that pays their partial income until they can return to work. Generally, this amount is two-thirds of your average weekly income before the injury, up to a statutory maximum. State laws differ on the benefits paid, so check your state laws or speak to your attorney.
If you suffered a permanent loss of function, you may be entitled to permanent total or partial disability. You will need to have an impairment rating assigned to you by your treating doctor, which will dictate the benefits you qualify for.
Why Are Workers’ Compensation Cases Denied?
If you feel disappointed that your claim did not receive approval, that is normal. Fortunately, denying your workers’ comp claim doesn’t equate to losing your case. An experienced workers’ compensation attorney can guide you to get your case reviewed and, hopefully, approved during the appeals process. Some of the most common reasons for denying claims include:
- You suffered the injury before the accident at work occurred.
- You did not take time off for medical treatments.
- You did not report your injury on a timely basis.
- The injury did not happen at work or during employment.
- You didn’t need medical treatments for the injury.
- There was incorrect or missing information on your workers’ comp application.
Here are more details about common reasons claims face rejection:
- Non-work-related injury: If the insurance provider says your injury was unrelated to work, they may deny your claim. For example, they may argue that the injury occurred when you were driving to work and not engaged in work at the time.
- The company disputes your claim: Your company may say that your injury wasn’t related to work. They can say it happened when you were engaging in horseplay and many other reasons.
- You reported the injury late: Every state allows a limited time to report a work-related injury. That is why you should report the injury to your employer as soon as you notice it. You should refer to your state’s statute of limitations for more information about deadlines for filing a workers’ comp claim.
- The report was incomplete or inaccurate: be sure to provide enough information about the injury, where it happened, and your medical care. Failure to do so might result in the denial of the claim. Your attorney will ensure you provide complete information in your initial report to prevent questioning.
- You didn’t seek medical attention: If you did not get medical treatment quickly after the accident, it may lead to questions and even a denial. The insurance company may claim that you didn’t get medical care within 24 hours, so the injury was minor. You must always undergo medical treatments for an injury to qualify for workers’ comp, and the sooner, the better.
- Mental injuries: Stress-related injuries, while not always rejected, are harder to prove due to their non-physical nature. If you have an injury such as anxiety from a toxic workplace, talk to your attorney about how to prove it.
- Differences between claims and medical reports: If there is any inconsistency between what your claim and the medical reports say, they may deny your claim.
Any injury on the job, whether due to a vehicle crash, defective equipment, or a slip and fall, should lead to the payment of workers’ compensation. However, workers’ compensation claims often end in denial. A denial is especially common if the injured party lacks an attorney to ensure filing paperwork correctly and presenting medical evidence effectively.
Many accident victims only seek an attorney when their initial workers’ comp claim faces denial. The attorney can often successfully appeal the case, but it is better to have an attorney help with your workers’ comp claim from day one.
Consider An Informal Meeting With Your Employer
Every state has an appeals process for workers’ comp claim denials. Before starting the official appeals process, you and your attorney may want to meet informally with your employer and insurance company about the denial. You should bring the denial letter you received to this informal meeting. If you and your lawyer can resolve the matters that led to the denial, you can avoid the hassle of the formal appeal process and get compensation faster.
Before you meet with your company, review the denial letter with your attorney and understand why it happened. By law, the insurance company must explain why they did not approve the claim. This way, you can take steps to provide the information they need to approve the claim.
For instance, workers’ comp claims face denial due to a lack of evidence that the accident happened on the job. You must show convincing evidence that the accident happened at work or during employment. For example, you can rely on the testimony of other workers who saw the accident occur. Or you can include video footage of the accident.
Workers’ Comp Claim Appeals Process
If an informal meeting with your employer and their insurance company isn’t productive, you must file an official appeal. Every state provides an appeal process if a workers’ comp claim faces rejection. The process will vary somewhat based on the state where you suffered an injury. For example, in Indiana, you must file an Application for Adjustment of Claim after your workers’ comp case is not approved. The state workers’ compensation board will assign the matter to a workers’ compensation board member.
Based on the circumstances, you must fill out the application within two years of the date of injury or within a month of getting notification of your claim denial or award that you think is insufficient. Your state’s workers’ compensation board should inform you of the hearing date and location. Each side can ask for a delay or continuance for the appeal hearing.
Attending the appeal hearing without a lawyer is not advised. Your employer will have an attorney. This means you will face opposition with deep financial and legal resources, making it harder to win the appeal without a lawyer. Hiring a workers’ compensation appeal attorney is strongly recommended to ensure the best results in your appeal.
Both sides will present their best evidence during the appeal hearing, but you have the burden of proof as the injured worker. You and your attorney must show that your injuries occurred during work or the normal course of employment.
In most cases, medical evidence is vital information in an appeal case. Once you and the other party have presented evidence, the person overseeing the hearing will make their determination and announce the results. Then, each party will know what to do and make conclusions according to state law.
If you are still unhappy with the workers’ comp case outcome, you can usually appeal the decision for a full board review in your state. In Indiana, this requires you to complete an application called Application for Review by Full Board. File your appeal promptly; most states mandate appealing to the full board within 30 days of the latest decision. The full board has a few months to hear most states’ cases.
What Occurs During A Full Workers’ Comp Board Hearing?
Before your state’s full workers’ compensation board, the hearing process will go similarly to the hearing with one board member. But you will now have several members listening to your appeals case.
Once the full board has heard the arguments from both sides and reviewed the evidence, it will issue an award and show it to both sides. You have taken your appeal as far as possible in most states. Your state’s Court of Appeals must handle any additional appeals you decide on. If that does not resolve the issue, your attorney can potentially send the case to the state supreme court for review.
Hopefully, you do not need to take your appeals case to the Court of Appeals or the state supreme court. Choosing an experienced workers’ compensation appeals attorney will often allow you to avoid having your claim rejected in the first place. Your attorney can build a convincing case and use strong evidence to encourage the insurance company to offer fair compensation.
You always have the best opportunity to win a workers’ compensation appeal by involving an attorney as early as possible. Hiring an attorney to help file the initial claim is even better, as they can navigate the complex process and ensure all necessary documentation is in order from the start. Your attorney receives payment from any settlement they obtain for you, so there are no out-of-pocket legal expenses, providing you with valuable support and guidance throughout the entire process.
Contact A Workers’ Compensation Appeals Attorney Today
Being injured on the job is always upsetting. However, if you apply for workers’ compensation and the claim faces denial, you may experience even more confusion and stress. The good news is that every state has an appeals process for when a workers’ comp claim faces denial. If you want to appeal the recent adverse decision, contact an experienced workers’ comp appeals attorney. Your workers’ compensation lawyer will review your case carefully and determine the best plan of attack to appeal the case. Contact an attorney today!