Workers Comp

When Workers’ Comp Won’t Pay: 3 Steps to Take

A workplace injury is never ideal. The silver lining, though, is that in the United States, in every state except for Texas, employers are required to carry workers’ compensation insurance. Workers’ comp is an insurance that protects both an employer and an employee in the case of a workplace injury.

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Workers rely on this safety net for protection, so when a claim gets denied, your safety net is cut, and you continue to fall towards the ground. Fortunately, you are not without options. There are several steps you can take to appeal your claim denial and have a trapezist swing in at the last moment and pluck you out of the air before crashing to the ground.

How Does Workers’ Comp Work?

Workers’ compensation is in theory, a hassle-free way for an injured worker to get compensation for their injury so that they can pay their medical bills, rest, recover, and hopefully get back to work. Workers’ comp protects employers from having to defend themselves in court cases every time that an employee gets injured at work.

For large companies in dangerous industries like construction, workers’ comp provides protection from countless hours of litigation every year. Without workers’ compensation insurance, between the money spent on defense and the eventual payouts to workers, many companies would not be able to survive the financial toll of employees getting injured.

Normally in a workers’ compensation case, immediately following an injury you would go to your supervisor to report the incident. Obviously, if the injury is severe enough, you would first go to the hospital and then notify your employer after you have been treated. Once informed, your employer should give you a claims form to fill out.

If you weren’t rushed to the hospital, you should receive a recommendation for an approved physician to treat your injuries. After you submit your claim, you will be contacted by a representative of your company’s insurance. After this, your claim should be approved, and you should be able to start receiving your workers’ comp benefits. These benefits should cover your medical costs and partial costs for lost wages.

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In cases of a severe injury, where you are unable to fully recover and cannot return to work afterward, you should receive a large settlement payment as well. This money can help cover the cost of future lost wages and other secondary expenses.

Unfortunately, things don’t always go as they should. Workers’ comp claims can be denied for a variety of reasons. Sometimes, claims get denied for legitimate reasons. Other times, the denials are completely bogus. Most of the time, they fall somewhere in-between.

Some possible reasons that your claim may be denied include if the insurance company believes you:

  • Were under the influence of drugs or alcohol
  • Were fighting
  • Were playing games rather than working
  • Suffered your injury away from work
  • Exaggerated your injury
  • Failed to inform your employer of your injury in time
  • Failed to file claim papers on time
  • Did not receive medical treatment
  • Were not treated by an approved medical provider
  • Missed doctor’s appointments
  • Failed to follow medical advice
  • Were injured as the result of a preexisting condition

How Can I Appeal My Claim Denial?

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In a situation where your claim has been denied, you are most likely going to want to appeal the decision and to continue fighting to get the compensation that you deserve. There are five main steps you can take to continue fighting your claim denial.

Step One: Hire an Attorney

Filing an original workers’ compensation claim is something that most workers can manage on their own without a problem. However, when it comes to appealing a denied claim, bringing in an experienced workers’ compensation attorney to help make sure your case is strong is always a good idea. With the guidance of a lawyer, it is possible to get a personal injury payout for serious work injuries. Learn more about hiring a workers’ compensation attorney.

Step Two: File an Appeal

When a workers’ comp claim is denied, you will receive a letter that will contain information about why your claim was denied. This letter should also contain information about when and how to appeal the decision, along with a notification of the deadline to appeal. Make sure to file your appeal before the deadline, as failure to do so potentially forfeits your claim.

Step Three: File a Workers’ Comp Complaint

If you have evidence that your claim was denied due to fraud, administrative error, or other irregularity, you can request a complaint form from your state’s workers’ compensation officials. A valid complaint can help your case and possibly improve your settlement amount.

Step Four: Request to Reopen a Workers’ Comp Claim

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Even if your appeal has been denied and your complaint is determined to be invalid, you are not necessarily out of options. It can still be possible to have a closed claim reopened, sometimes years after the claim has been finalized. In some instances, you may even reopen a claim that was not denied to receive further support beyond the initial ruling.

Some common reasons to reopen a claim include:

  • New evidence that proves the validity of your claim
  • New evidence that shows your original award amount was unfair
  • New evidence proving an administrative error that affected your claim
  • New evidence of fraud
  • A return or worsening of your injury

Step Five: Request an Administrative Hearing

When you don’t feel like you are going to get a fair decision from the insurance company, you can request an administrative hearing. An administrative hearing puts your fate at the mercy of the administrative judge rather than the insurance company. This is often a welcome path for those who file workers’ comp claims, as insurance companies are notorious for doing everything they can to pay out as little as possible.

Should you end up requesting an administrative hearing, if you haven’t already hired a workers’ comp attorney, now is the time. You can bet that an insurance company will be bringing their full legal might against you to try to defeat your case and hang on to their money. Attempting to take on these highly experienced professionals without one of your own is like bringing a knife to a gunfight.

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A Denial Can Be Devastating

Having a workers’ comp claim denied can leave you feeling hopeless. When the injury you suffered on the job is severe, you are already left with so many question marks in your life and possibly face many life changes. Being told you will not receive financial compensation to help you deal with everything can be the straw breaking the camel’s back.

It’s important to know all of your options when faced with a situation like this so that you have all of the tools you need to fight this decision and get the compensation that you need and deserve.

What Qualifies You for Workers Comp

There are two main factors that will determine whether or not you are eligible for workers’ compensation. These are the type of employee you are and the type of injury or illness you’ve sustained. To qualify for workers’ comp, your condition must have happened while you were performing job-related duties. 

The Types of Employment That Qualify

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If you are an employee of a company, you qualify for workers’ comp benefits. This includes full-time employees, part-time employees, temporary workers, and seasonal workers. There is no minimum period of time that you’re required to be with the company before you’re eligible. Any employee is eligible, period. 

Freelancers, get ready for the bad news. Freelance workers, independent contractors, volunteers, and consultants are not eligible for workers’ comp benefits. The good news is you can get your own workers’ compensation insurance coverage. In certain situations, your injury or illness may be covered even if you work from home. 

Often employers miscategorize workers. This can be on accident, such as someone who is just starting a business and doesn’t understand the laws. This can also be deliberate, which would apply to someone who owns a business and wants to save money by treating you like a 1099 independent contractor when you actually are an employee under the law. 

These are some of the situations that could make you an employee, even if your employee says you’re a contractor:

  • You must work in the office
  • You must work certain hours
  • You are under someone else’s direction
  • Taxes are being withheld from your paycheck

Independent contractors are paid for the finished product. As long as you meet your deadlines, how, where, and when you complete the work is up to you. If you work so many hours for a company that you don’t have other clients, you may also be an employee. 

If you were injured on the job and you believe you are an employee but your employer says you are not, you have rights. Before you accept your employer’s denial of workers’ comp benefits, you may want to speak to a lawyer. Visit here to learn more about workers’ compensation attorneys in your area. 

The Types of Injuries and Illnesses that Qualify

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If your illness or injury happened while you were performing work related to your job, you will most likely be covered. This includes conditions that happened in the workplace and outside of the workplace while you were carrying out duties related to your job, such as running errands, attending office functions, or being injured while telecommuting. 

These are some of the types of injuries that are covered:

  • Cumulative trauma disorders
  • Repetitive stress injuries
  • Illnesses from exposure to toxins
  • Slip and fall injuries
  • Injuries from machinery
  • Automobile accidents
  • Workplace violence

Conditions that happened while you were commuting or on your lunch break wouldn’t be covered. Business owners, partners, part-time domestic workers and gardeners, taxi drivers, intermittent workers, longshoremen, federal employees, and railroad workers are also not covered. In most cases, injuries that are related to stress or mental illness are not covered.

When a Workers’ Comp Claim May Be Denied

Some of the most common reasons claims are denied include the employer not believing you were injured at work or an injury that did not cause you to miss work or receive medical treatment. Some employers will not file a claim if your condition can’t be medically verified, such as unexplained chronic pain. 

Some claims may be denied because there were no witnesses to the injury or there is no video footage from security cameras. If there are discrepancies in your report or you don’t cooperate with the process, you may also be denied. If it’s determined that you had a pre-existing condition that caused your injury, they will also use that to reject your claim. 

Other reasons a claim can be denied are related to the employee’s actions. These are the main categories. 

The Employee Was Under the Influence

According to one study conducted by the University of Buffalo Research Institute on Addictions, 2.1 million American workers have worked while they were under the influence of alcohol. The National Safety Council has reported that 75% of adults with a substance abuse problem are participating in the workforce. If you are one of them, your claim may be denied. 

Misconduct

Employee misconduct is another reason your claim may be denied. This includes horseplay, breaking safety protocol, and any other situation in which it can be demonstrated that you knew the potential consequences of your actions but chose to risk your safety anyway.

Workplace Violence

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If you were the instigator in an act of workplace violence, you can also kiss your workers’ comp claim goodbye. Only the victims of violence qualify for this coverage. If you were the aggressor and you received an injury, you’ll be responsible for your own damages.

What to Do if Your Claim Is Rejected

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If your claim is denied, try, try again. According to Risk and Insurance, nearly 70% of denied claims end up being converted and paid within the first year after appealing. Only 5% of cases end up going to trial. The odds are in your favor, so it’s worth taking the time to contact your employer’s insurance carrier to see if you can work out a solution.

If this doesn’t fix your situation, you’ll need to get a lawyer who can help you request a hearing with the state’s board. You can also sue your employer if you believe they are deliberately interfering with your claim or refusing to file it. 

If you decide to settle your claim, your lawyer will negotiate with the insurance carrier for a fair settlement, which will then be paid out as a lump sum or as a structured settlement. If you don’t think the settlement is enough, you can choose to go to trial, but this is a more expensive and riskier option. Your attorney can tell you what the best option is for your situation and don’t hesitate if you find yourself in one of the above mentioned cases.