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.
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.
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?
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
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.
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.