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5 Things to Know If Your Worker’s Comp Claim is Denied

5 Things to Know If Your Worker’s Comp Claim is Denied

Workers’ compensation is a type of government-mandated insurance providing benefits to workers who get sick or injured on the job or due to their job. Workers’ comp is like a disability insurance program for workers. The program provides cash benefits and healthcare benefits. 

The individual states handle most of the workers’ comp system in the U.S., so benefits vary by state. The only state that doesn’t require employers to have workers’ compensation insurance is Texas. 

Benefits might include partial wage replacement when an employee can’t work, as well as reimbursement for medical care they receive and occupational therapy. Most workers’ comp programs are paid by private insurers, and the individual employers pay the premiums. 

If someone is hurt at work, they have to let their employer know about the injury as soon as possible. The employer typically handles it from there and is usually responsible for filing the claim with the insurer. 

Only salaried employees are eligible for workers’ compensation, but not contractors or freelancers. 

Claims can be denied, however, and the following are things to know if you find yourself in that situation. 

1. Reasons Claims Are Denied

There are a few key reasons a workers’ comp claim might get denied. One is if your injury didn’t actually happen at work. For example, if you were on your lunch break when you got hurt, you might have physically been on the premises of your workplace, but still, you wouldn’t be eligible for workers’ compensation. 

Other reasons claims might be denied are:

  • You didn’t let your employer know about your injury within the required time limits. Your employer has to know right away, and they need to have time to carry out an accident investigation. 
  • Claims can be denied if someone was under the influence of drugs or alcohol when they were hurt. 
  • Within the workers’ compensation system, your employer and the insurance company can provide you with an approved list of providers where you can receive treatment. You have to see an approved provider to be entitled to compensation. 
  • If you don’t get medical treatment at all, then there’s a high likelihood of your claim being denied. 
  • There are particular deadlines for filing a claim, so if you aren’t within that, you may end up with a denied claim. 
  • Your injury is from a pre-existing condition. If you had an injury or illness before you started your job and your job didn’t make it worse, you’re probably not going to be eligible for workers’ compensation. An insurance company will fight hard to get your claim rejected if they think you have a pre-existing condition. 
  • Your employer might dispute your claim. In fact, they very likely will. Employers fight claims because their insurance coverage goes up if there’s a claim on their policy. To try and get around the price increase, an employer might argue the details of the case or say that you weren’t at work when you got injured. 

2. What to Do

If your claim’s denied, don’t give up immediately. You should look carefully at the letter you receive that will detail why your claim was denied. The reasons for the denial should be listed within the letter. There may be something you can correct easily, like a mistake you made on paperwork. 

If the mistake is simple and can be cleared up, you can talk to the claims adjuster and see what they can do. 

If there’s a more complicated mistake or situation, then you’ll have to consider an appeal. 

3. Starting the Appeals Process

When you get a letter, it will include information on how you can appeal your denial. The appeals process varies depending on your state. 

In many cases, the first level of an appeal is a hearing. You will go in front of an administrative law judge, and then you can present your supporting evidence for your claim. 

The hearing might be done through a state board of workers’ compensation or the state labor department. 

Make sure you’re mindful of the time limits for filing an appeal. You may have a window of time as short as 30 days once you receive your denial. 

4. Consider Hiring an Attorney

The appeals process for workers’ compensation can be difficult to navigate. The process varies by state, but you should very seriously consider working with an experienced workers’ compensation attorney. 

There can be multiple levels of appeal that you have to go through. An attorney will be able to help you understand what those levels are. 

An attorney can help you figure out the best course of action. You want to make sure that you aren’t missing deadlines that will cause you to waive your right to benefits because you don’t know what those deadlines are. 

If you don’t win at the early levels of the appeals process, you might not be able to present more evidence later. One of the most common reasons people who are injured at work lose their appeals is because they didn’t work with an attorney. 

5. Working With an Attorney On an Appeal

A workers’ compensation attorney is paid a percentage of the benefits from your claim, so you don’t have to pay them upfront. A lawyer will work to figure out why you were denied, and then they’ll start gathering evidence. An attorney will also contact potential witnesses and, if necessary, get experts from the medical field and the industry you work in. 

Most claims are denied for medical reasons, so your attorney might hire an independent medical specialist. They can also talk to your health care provider to figure out if a more detailed report from them might be useful. 

If you’re in a state that doesn’t use administrative law judges, then an appeal is going to be heard in front of a review board. 

Finally, if the review is denied, the step might be an appeal to the Workers’ Compensation Court of Appeals or another appeals board, depending on the state. At this review level, only the record of the hearing is considered. You can’t introduce new evidence. There’s no near hearing either. 

About the author

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Miller Willson

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