Note: Daryn’s story is a fictional scenario presented to illustrate how a workers’ compensation claim can be denied and appealed.
Introduction
Sometimes, an insurance company will deny a workers’ compensation claim. If this happens, know that a denial is not necessarily the end of a workers’ compensation claim. You still have legal options if you decide you want to fight back.
Why Was It Denied?
Answering this question is an important first step. Your claim may be denied if:
- The type of injury/illness is excluded from coverage
- Your medical report or the expense of treatment does not match your claim
- The employer or insurance company suspects fraudulent or exaggerated claims
- You lack evidence and witnesses, or the injury/illness is difficult to prove in your state
- Your documentation (of the incident or medical care received) is inaccurate or incomplete
- The injury or illness was not work-related (for example, you were on break, or your employer argues that your symptoms are due to a pre-existing medical condition)
- You were hurt because you violated company policies or procedures (such as goofing off with a coworker and being harmed in the process, or refusing to wear proper PPE and getting Covid from a patient because of it)
- The injury or illness was not reported within the required window of time (every state has a different statute of limitations)
- You failed to seek medical attention for it, which suggests it was not severe enough to warrant a workers’ compensation claim (medical treatment is often required to receive benefits)
The insurance company’s explanation for not covering your claim should be stated in a denial letter. Also in the denial letter should be a deadline— determined by state law— for filing your appeal.
Filing an Appeal
Before filing an appeal, it’s good to meet with your employer to see if the dispute can be resolved, as it is possible the denial was a miscommunication. Once you determine the claim was denied and discover why it was denied, you can file an appeal with your state’s Workers’ Compensation Commission.
It’s possible the commission could also deny the claim, in which case you could take your claim to the court of appeals. Appealing decisions requires knowledge of state law, evidence to support your claim, and detailed paperwork. A lawyer can assist you with all of these tasks.
What Are Your Next Steps?
Your next steps may depend on your case, as everyone’s circumstances are different. We advise you do the following:
- Attend required hearings, if any. Be prepared to present your case and answer the judge/hearing officer’s questions.
- Consider negotiating a settlement with the insurer.
- Consider mediation. Mediation is a legal term for the process of a neutral third party, or mediator, helping people resolve a dispute. This occurs in a neutral location, typically with both parties in the same room. The mediator has no authority to make a decision or force the parties to settle. They simply help the participants negotiate more efficiently and reach an agreement sooner than they could on their own.
- Keep organized records of everything related to your workers’ compensation claim, especially since records can be used as evidence. This includes all communications, documents, and medical expenses.
How We Can Help
The best way to navigate an appeal is by calling on the help of a workers’ compensation attorney. We can:
- save you time
- represent you in court
- advocate for your rights
- help you build your case
- figure out your next steps
- provide all supporting documents
- educate you on current legal requirements
- communicate with the insurance company on your behalf
- advise you on whether negotiation or mediation is a good option in your situation
How To Fight Back in 2024
A lawyer can also help you stay informed on what the current laws are in your area. Workers’ compensation laws are subject to change over time to address emerging issues, enhance worker protections, and adjust benefits in alignment with where our economy and society are currently positioned. We can take all of this into account when we inform you of what your legal options are.
Daryn’s Story
Daryn works at the Apple Store in a shopping mall, helping customers troubleshoot issues with their devices. One day, while assisting a customer with a heavy desktop computer, Daryn slipped and fell, resulting in a severe back injury. The pain was immediate, and Daryn was unable to continue working that day.
Daryn filed a workers’ compensation claim for his physical injury, hoping to be compensated for the medical expenses and the time he had to take off work for recovery.
His claim was denied because the insurance company argued that the injury was due to a pre-existing condition and that Daryn did not report the incident immediately. He decided to appeal the denial.
He retained a lawyer to prove that the medical bills and lost wages were a direct result of the injury sustained at work and that he did not have any pre-existing back conditions.
In the end, the insurer finally agreed to reimburse him.
Conclusion
Was your workers’ compensation claim denied? If so, we assure you, it is within your right to fight back. The sooner you get a lawyer to appeal the denial, the better.
The Law Offices of Craig L. Cook can help you win your case and get the benefits you deserve. All you have to do is book a free consultation with us, and we will assign an attorney to your case.
You don’t have to financially suffer from a work-related injury or illness. Contact us today! We are on your side.
