Workers’ Compensation Denials FAQs

Worker’s compensation exists to provide financial support and medical care to employees who are injured or who suffered an illness that is related to their employment.  If an individual is injured as a result of a work related activity, or something that occurred or regularly occurs in the course of their work, then that person can file a claim for workers’ compensation. Most places of employment are required to keep workers’ compensation insurance policies.

Many employees who apply for workers’ compensation benefits later find themselves faced with a denial of benefits. If you ever find yourself in the unfortunate situation of being denied workers’ compensation benefits, here are some frequently asked questions and things to keep in mind as you are deciding what to do next.

Why was my claim denied?

Workers’ compensation benefits are often denied. Insurance companies and employers are not usually happy about the money the claim will cost them, and so the assessment of claims is done diligently to look for anything that might make an employee’s claim questionable or possible to deny.

There are plenty of different reasons a claim might be denied, and sometimes denial notices will explain the reason for the denial. Some more common reasons for claims to be denied include the timing of your claim. Rules regarding how soon an employee is required to report the claim to his or her employer, and rules regarding how soon the claim must be formally filed will vary by state, but they are typically rather short. Furthermore, sometimes the type of injury will make it difficult to determine when the need to report the injury is triggered- if the employee is suffering from an injury that developed over time, when did the clock start ticking? The same problem exists with an illness. Oftentimes, the first time an individual sees a doctor, or misses work will be the beginning of his or her time frame to report, but sometimes facts can make this a more complicated issue than it would seem on its face.

Another reason for denials is that something is wrong with the medical records. Perhaps certain records are absent or incomplete, perhaps there is no evidence the employee even saw a doctor, or maybe the evidence of the injury is just disputable. Sometimes employees are required to see a doctor who does an exam for the insurance company, and if the individual fails to comply with the requirement, their claim might be denied. A successful claim requires very thorough and complete medical records.

Sometimes the denial of a claim has to do with a determination that the claim was not in fact work related. If the insurer believes there is a preexisting condition that caused it, or an injury that occurred elsewhere, the claim could be denied. Sometimes employers actively challenge the assertion that the injury is work related leading to a denial of benefits. Naturally, many other reasons exist as well.

What can I do if my claim was denied?

If your claim was denied, you have the right to appeal it in most cases. You should keep in mind that the timeframe in which you can file an appeal is rather short. You should do so as soon as possible. The appeal process with start with a hearing in front of an Administrative Law Judge. The process of appealing will be different in different states.

What if my employer retaliates against me for pursuing workers’ compensation?

There are laws in place to prevent your employer from retaliating against you for filing a workers’ compensation claim. If you have reason to believe this will happen to you, be sure to keep records of anything that seems to give you this impression, as well as records of your employment reviews, and anything else that could be used to show that you are a good employee, and being treated unfairly.

If my claim was denied, can I just sue my employer?

Probably not right away. Workers cannot sue their employer in a court of law, but rather, must go through the process of the workers’ compensation program. Once an employee has been through that process, he or she might be able to take their case to court.

Do I need an attorney?

You should consider speaking with an experienced attorney in order to get advice specific to your case and the laws of your state. An attorney can help you develop a strategy for taking on the process of appealing your workers’ compensation claim.

Contact Stern Law, PLLC for A Free Consultation

At Stern Law, PLLC, we have compassionate and caring attorneys ready to work with you in order to find the best strategy for seeking compensation for your job related injuries. Contact Stern Law, PLLC today at (844) 808-7529 for a free consolation with an experienced attorney.

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