Having a workers’ compensation claim denied by an employer or insurer can be quite a blow, but it does not have to be the end of the story. Most insurance carriers, employers or states have protocols for appealing a denied claim and obtaining rightful compensation.
The methods may vary greatly between states, but the idea is generally the same. By providing extensive evidence regarding your claim and complying with all deadlines and paperwork requirements, you can defend your claim and possibly convince the insurer, employer or the state to reconsider a prior denial.
Know the Facts Surrounding Your Denial
A denied claim is almost always accompanied by a letter informing you of the decision. This document will frequently list the reasons for your claim being denied. Follow up on this information, or lack thereof, by contacting your employer and your insurance carrier and requesting additional disclosure on the nature of the denial and the stated reasons for being denied.
Build a Case
Assemble as much information about your medical claim and how your condition was directly caused by workplace duties or conditions. Provide written statements, medical files, copies of documents like those obtained through visits to the doctor or provided by witnesses as needed or appropriate to the nature of your claim.
You can often piece together information to form a timeline regarding the denial and the incident to locate problem spots where miscommunication or alleged misconduct occurred. Even if your claim was denied for reasons that seem irrefutable, like a deadline lapse or a failed drug screening, you can often dispute the circumstances by bringing new information to light that could have affected the denial decision. For example, a previously disclosed prescription drug that could have affected the screening or a recent diagnosis leading to the medical claim can strengthen a denial’s appeal in certain scenarios.
Follow Through with the Designated Appeals Process
Your letter informing you of a denied claim will often contain procedure on how to dispute it. If no such instructions are provided, you can follow through with the appeals process appropriate for your state. Pay close attention to any deadlines or needed paperwork that may apply to this process.
Each state’s process may vary, but it typically begins with a hearing arranged by the state’s labor department or the state board of workers’ compensation. An administrative law judge will hear your case as well as the case of the insurer or your employer. Be prepared to use the documentation you procured while building your case, including medical and factual evidence.
Consider Consulting an Attorney
There are often attorneys who specialize in disputing denied workers compensation claims and representing parties injured at the workplace. They can assist you with filing your appeal and developing the type of compelling evidence that may affect case outcomes.
Use discretion as to the type of attorney you hire since the outcome of your case can be greatly influenced by the knowledge, skill and personal motivations of the person you hire. Also keep in mind that most attorneys require you to split the awarded claim amount should they win the case, so weigh your need for representation based on the difficulty of the appeals process and the likelihood that you could be unprepared to back up your case to the fullest extent possible.
Hopefully, by going through the appeals process the outcome will favor the truth of the matter and resolve any confusion or ill-judged decisions. Millions of people have been protected by the workers’ compensation system, so no one should be allowed to fall through the cracks unfairly.