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Workers' Comp Denied? Here Are Your Next Steps

Workplace injuries are generally covered by an employer's workers' compensation insurance. This is an insurance program that benefits workers who have suffered a personal injury or illness due to their job. The insurance company handling the workers' compensation benefits handles compensating injured workers. This financial assistance is used for lost wages, medical expenses, and other related costs.

However, not all workers' compensation cases are approved. Sometimes, the insurance company might deny a workers' compensation claim. This can leave injured employees without help. Many states require employers to be covered. Nevertheless, if your claim for workers' comp is denied, you still have options. You may appeal the denial through your state's board of workers' compensation. However, there are various reasons why a claim may be denied.

This article will help you determine what steps to take if your claim for workers' comp is denied. Keep in mind that specifics will vary by state. See FindLaw's Workers' Compensation Basics section to learn more.

Why Workers' Comp Claims Are Denied

If your claim for workers' comp was denied, the first thing you need to do is determine the reason why. This should be explained in the denial letter. You could be denied for not meeting the eligibility requirements. Still, you may appeal if you believe the denial was reached in error.

There are several reasons why an insurance company might deny a claim. Understanding these reasons can help injured workers better navigate the claims process. Common reasons for the denial of works' comp benefits include (but are not limited to):

  • Non-work-related injury: If the insurance company believes the personal injury was not due to a work-related injury, they can deny the claim. For instance, they might reject the claim if the injury occurred outside of work or is due to a pre-existing medical condition.
  • Employer disputes claim: Your employer may claim the accident was non-work-related. They might argue that the claim happened outside of work due to horseplay or some other disqualifying reason.
  • Late reporting: Workers' compensation laws require injured employees to report their job injuries. It should be reported to their employer within a particular time. The insurance company might only accept your claim if you report your injury in time. Check your state laws' statute of limitations for workers' compensation claims.
  • Incomplete or inaccurate documentation: Providing insufficient information about your injury and medical care can result in claim denial. This might include incomplete medical records, inconsistent statements about the injury, or failure to provide requested documents.
  • Failure to seek medical attention: If injured workers do not seek immediate medical attention after their injury, it can lead to claim denials. The insurance company might argue that the lack of immediate medical care implies the injury was not serious. You must obtain medical treatment in order to receive workers' comp benefits. The bottom line: if you are hurt, seek medical care immediately.
  • Injury is not compensable: Claims for stress-related injuries, for example, are difficult to prove in many states. By contrast, California workers' comp laws specifically cover stress-related injuries.
  • Discrepancies between medical reports and claims: If there are inconsistencies between what the claim says and what medical bills or reports indicate, the insurance company may deny the claim.

There are plenty of other reasons why your workers' comp claim may have been denied. In the event of a denied workers' comp claim, injured workers have the right to appeal the decision.

Appealing a Workers' Comp Denial

You may appeal the decision once you know why your claim was denied. This process typically involves filing an appeal. This appeal is filed with either the workers' compensation commission or a similar agency your state may have. If the commission also denies the claim, the injury claim can be taken to the court of appeals.

The denial letter should provide a deadline for filing your appeal. The deadline is determined by state law. In Maryland, for example, you must file your appeal within 30 days of receiving the denial letter. Before you launch an appeal, you should meet with your employer to determine whether the dispute can be resolved. It could be a clerical error or a simple misunderstanding.

If you still want to appeal the decision, remember that it can be a complicated legal process. An experienced workers' comp attorney is best equipped to handle it. The appeal process can be complex and requires detailed knowledge of workers' compensation laws. It is essential to provide clear and consistent evidence to support your claim. This includes comprehensive medical records that show the extent of your injuries. The paperwork should also show the associated medical expenses.

The appeals process varies by state but often involves a hearing before an administrative law judge. This may occur through the labor department or the state workers' compensation board. There may be multiple levels of appeal, but it is essential to check your state's laws for specifics. Talk to a legal professional for more help.

Get Professional Legal Help With Your Workers' Comp Appeal

Was your workers' compensation claim denied? You may feel defeated by the denial letter but do not despair. In many cases your denial may be successfully appealed, but you may want to work with an experienced legal professional to make sure everything is handled correctly. Accepting a denial of benefits can be financially devastating, so you need to have a strong ally in your corner.

Navigating the world of workers' compensation claims and claim denials can be challenging. That is why it is crucial to seek legal advice if your claim is denied. An experienced attorney can help guide you through the appeals process. A workers' compensation attorney can also help represent you in hearings or in court.

The law offices of a workers' compensation attorney can provide advice tailored to your specific case. They can help you understand your rights, show you the best way to move forward, and communicate with the insurance company on your behalf. This can be very helpful when overturning a workers' compensation denial. Working with an attorney increases your chances of receiving the benefits you deserve.

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