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Workplace injuries are typically covered by workers compensation insurance and as an injured employee you are entitled to workers’ compensation. If you have a claim that is denied, there are still options. You may be able to appeal the denial.
Why Claims Are Denied
In order to know your options, it helps to know why your claim was denied in the first place. There are several reasons why a claim can be denied and the reason for your denial will be explained in the denial letter. If you think the denial was an error, then you may appeal. There are some common reasons why claims can be denied, including:
Missed Deadlines: Not only does the injury need to be reported on time, but the claim also needs to be filed in time. If you miss any of the deadlines, then it’s likely the claim will be denied.
Disputes If the Injury Is Actually Work-Related: You will need to have evidence to support your claim, whether it’s a witness account about the circumstances or some other documentation.
The Condition Doesn’t Meet the Guidelines: The laws in the state could have restrictions on claims for psychological conditions or cumulative trauma.
You Filed a Claim After You Left a Job: Insurers may automatically deny claims that are filed after the employees quit, were laid off, or were fired. Even though you may have had a good reason for the delay, it’s still likely that the claim will be denied, and you will have to go through the appeals process.
Other Red Flags: Some claims have red flags and adjusters are trained to think that these are suspicious. For example, if a claimant comes in on a Monday morning with a report that he or she was injured on Friday at work, but there is no report to a supervisor or witness, then this is automatically seen as suspicious. These red flags are common reasons why claims are denied. A situation like this may need some more investigation. You should think about which facts could appear suspicious to anyone who doesn’t know the whole story like you do. You may need to clarify those facts by providing some witnesses or other information that can confirm the story. However, you don’t want the case to become confrontational and it’s always best to get legal counsel.
Appealing the Denial
When you know why your claim was denied then you have the option to appeal. The denial letter provides you with a deadline for filing the appeal and this is determined by your state’s law. Before you do in fact launch an appeal, it’s best to meet with your employer or the insurance carrier in order to see if you can easily resolve the dispute. It may be just because of a simple misunderstanding or clerical error.
If you are appealing the claim not because of a simple misunderstanding, then keep in mind that it can be a complicated legal process and it’s best to get an experienced workers comp attorney involved. The appeals process can vary but will typically include a hearing before a judge. There may also be multiple different levels of appeal that you need to go through.
Through the process, you will need to provide documentation, including medical records, that addresses any reasons for the appeal. This may also mean you need a second medical examination, time sheets showing you were at work at the time of the injury, or some other evidence.
Reopening a Workers Comp Claim
Reopening a claim is different than appealing a claim. You may choose to reopen a closed claim if the injury has worsened or returned, new evidence is found proving the injury claim, new evidence shows the compensation was unjust or inadequate, an administrative or legal error occurred, or fraud was discovered. There are going to be time limitations for reopening a claim. It’s based on the date of the original claim and not your injury. Some cases are going to be considered closed when final and full payment is made, and in this case, you or the insurance company won’t be able to reopen the claim. You will need to follow the rules set out in the application in order to reopen the claim. You will need a copy of the denial letter and provide supporting documents. For example, if the injury has gotten worse since the original claim, then you need to send in new medical information that diagnoses the condition. Even though it is legally possible, reopening a closed claim can be very difficult. Many workers compensation commissions are overworked with claims and will look at any possible reason to refuse the request.
Why Work with a Lawyer?
Unless you have a simple denial that can easily be cleared up, you should be meeting with an attorney as soon as you can. An attorney can first help you determine if the appeal is the right course of action for you. The timelines for appeals are strict and short and you don’t want to miss out on your compensation because you missed the deadline. Appeals are complicated and you don’t want to file by yourself unless you know the rules of evidence. If you don’t win at the beginning levels, then you may not be able to present any extra evidence later on in the process. One of the main reasons why an injured employee loses out on an appeal is because he or she didn’t have the experience of an attorney. Remember that workers’ compensation lawyers will only charge a percentage of benefits, so you don’t have to pay unless you win. There is no reason to not speak with an attorney.
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