Appealing Your Workers Compensation Claim Denial

If you suffered an injury at work, you have every right to believe that you should be fully compensated. Of course, this is under the condition that your employer and the insurance company are willing to play fair. Unfortunately, there are ways in which they can deny some of your rights and even go so far as to make sure your claim is denied.

The good news is that there is a process to follow for appealing the denial, and help is available along the way. In this article, you’ll learn why your claim was denied, how to overturn the decision, and who can help you throughout the appeal process.

Why is Your Worker’s Compensation Claim Denied?

If your workers’ compensation claim was denied, you have the right to know the reason and receive a detailed explanation from your employer or the insurance carrier. Furthermore, you should be informed about some of the main reasons why work comp claims for benefits usually get denied, which include:

• You’re claiming benefits for an injury that’s not job-related. For example, if you hurt your back playing tennis on the weekend, you can’t file a worker’s compensation claim for those injuries.
• You didn’t file the claim fully or notified your employer correctly. For example, if you didn’t see a doctor right away or report the injury to your employer within the required time frame, your claim could be denied.
• You missed the deadline for filing a claim. Deadlines are usually pretty strict when it comes to workers’ compensation, so if you even file one day late, your claim could be denied.
• The assigned doctor stated that you’re ready to return to work. If the doctor says you’re able to return to your job, then your claim for benefits could be denied. However, keep in mind that some medical professionals, especially when hired by the insurance carrier, are likely to minimize or deny your injuries, as they will be acting in the interest of the company, and not the worker.
• You used alcohol or illicit substances at the time of the injury. This is not an uncommon cause for denial, because if it’s determined that you were under the influence at the time of your injury, then your employer or the insurance company may not be held liable.

How do You Overturn the Denial?

This depends on many factors. If your claim was denied just due to a small technical mistake, you can probably fix it with a couple of phone calls or an email. More likely, you’ll have to enter a complex appeal process. This process can vary from one state to the other. When claiming benefits under the California work comp system, you would need to :

• Get a copy of the claim denial from your employer or insurance company. This should come with an explanation of why your claim was denied and what evidence was used to make that decision.
• File an appeal with the worker’s compensation appeals board within one year of the date you received the denial notice.
• The appeals board will review your case and make a decision. If they deny your appeal, you can file a petition for reconsideration.

What you need to collect in order to file an appeal:

• Your Notice of Claim Denial from the insurance company
• The reason was given for the denial
• Any evidence or documentation you have to support your cases, such as medical records or eyewitness statements
• Proof that you filed your claim on time and followed all procedures correctly.

If you think your employer is at fault:

• Gather any documentation or evidence you have to support your cases, such as safety reports or previous workers’ compensation claims.
• Get a copy of your state’s workers’ compensation law and look up the section on employer negligence.

If you think the insurance company is at fault:

• Request a copy of the medical records used to make the decision to deny your claim.
• Look for errors or omissions in the records.
• If you think the insurance company is wrong about your injuries:
• Get a second opinion from another doctor.
• Make sure the doctor understands that you need a detailed report of how your injury affects your ability to work.

How long does it typically take for the rejected claim to be appealed?

The length of time it takes to resolve a worker’s compensation claim can vary depending on the severity of your injuries, how long you were out of work, and other factors. However, the appeals process usually adds another few months to the timeline.

Who can Help You in Your Appeal Process?

There are a few different types of professionals who can help guide you through the process and give you the best chance at a successful appeal, such as an experienced workers’ compensation attorney in Orange County, a vocational rehabilitation counselor, or workers’ compensation claims adjuster

Oftentimes, the most effective way to win an appeal is to hire an attorney who specializes in workers’ compensation law.

An experienced workers’ compensation lawyer will know the ins and outs of the appeals process and will be able to help you build a strong case.

If you’ve been injured at work, don’t hesitate to reach out to a qualified workers’ compensation attorney in your area today.