You are at work, and an injury has happened. After getting hurt at your workplace, you follow every procedure to receive your workers’ compensation benefits. You contacted human resources, went to the medical examinations, and submitted yourself to seemingly endless questions, but you received a denial of your workers’ compensation claim and benefits. You might feel overwhelmed and confused, with concerns over how you will cover the costs of your injuries without benefits.
You likely have many questions. Why did this denial happen? What should I do now?
The best thing to do in this situation is to consult an experienced workers’ compensation attorney. They can review the denial reasons and advise on the best path to appeal and receive benefits.
Read on to learn more about what happens after a denied workers’ compensation claim.
Employers must carry workers’ compensation insurance to protect employees from workplace injuries. Workers’ compensation provides medical benefits to the employee during their employment in exchange for mandatory relinquishment of the employee’s legal right to sue the employer for negligence. Workers’ compensation laws aim to provide benefits and mitigate the financial burden of lost wages and new medical bills created by workplace injuries.
In most states, employers with more than a certain number of employees must carry workers’ compensation insurance. The requirement and minimum amount of coverage vary depending on the state. For example, some states require any employer with five or more employees to carry workers’ compensation insurance.
Workers’ compensation insurance covers only employees. An employee works in the service of another person or business under any contract for hire. Employers may periodically hire temporary employees to perform services like independent contractors, volunteers, or freelancers. These workers are not employees and do not have workers’ compensation insurance coverage.
When you initially apply for workers’ compensation benefits, the insurance company will assign you a disability status. They might categorize you as either totally disabled or partially disabled. If they state you are disabled, after 104 weeks, the insurer can require a medical examination.
If, after the test, you are at least 35 percent disabled, it is a total disability. If, after 500 weeks, you are less than 35 percent disabled, you will have a partial disability for workers’ compensation purposes.
The purpose of workers’ compensation is to cover the medical needs and other benefits an employee requires after getting hurt at work. Examples of benefits covered by workers’ compensation insurance include:
For employees eligible for vocational rehabilitation, your employer’s workers’ compensation policy should cover the costs of the service.
If your injury causes you to lose time at work or you can only return to light duty, your employer’s insurance provider must pay for your lost income or lost earning capacity.
Workers’ compensation benefits cover an employee’s required medical treatment. Treatment may include surgery, physical therapy, hospital stays, rehabilitation costs, or other treatment related to the injury covered by your employer’s workers’ compensation insurance policy.
If a workplace injury causes the death of an employee, certain surviving family members can recover death benefits from the workers’ compensation system.
You have already suffered an injury. Now, to add insult to injury, your claim was denied. The good news is this is not the end; you have options. If an insurer denies an injured worker’s claim, the worker has the legal right to appeal or reopen their case. The appeal process can be grueling. An experienced workers’ compensation attorney can be your best resource during a workers’ compensation appeal.
After an initial claim denial, you should speak to your employer. A simple conversation may resolve the issue. Denials might be due to a misunderstanding or a clerical error. You can avoid an appeal entirely by speaking to your employer or insurer. Better yet, have your attorney speak with them.
If your claim is not approved, you will receive a denial letter. This letter is essential, so read it carefully and note everything explained. Your denial letter will contain the reason the insurer denied your claim and the deadline for appeal. If you fail to meet the deadline for appeal, you may lose your right to appeal and receive workers’ compensation benefits.
If your case gets denied, then your case will proceed to appellate review. The procedures for appeals vary from state to state.
At the federal level, The Employees’ Compensation Appeals Board (ECAB) reviews the initial decision from the Office of Workers’ Compensation Programs. After the Office of Workers’ Compensation Programs (OWCP) makes a final decision, you can file an appeal with the Board.
The ECAB reviews the decision from the OWCP. Workers cannot submit new evidence on appeal. Each appeal is reviewed by a panel of judges considering the record and every argument the employee or attorney raises. Once they reach a decision, the judges’ panel must issue a written decision explaining why they denied the appeal or issued an order overruling the original decision.
Employees must file an appeal with the OWCP within 180 days after their initial denial. The review from the ECAB is the final decision. There is no further remedy for an employee seeking an appeal.
The Board may grant each side an oral argument to present their cases in front of the judges’ panel. Oral arguments are at the sole discretion of the Board.
The appeals process is unique in each state. If you have suffered an injury on the job and received a denial of benefits, contact a workers’ compensation attorney in your area immediately.
If you need to file an appeal with the Office of Workers’ Compensation Programs, there are some documents that you will need to appropriately file your appeal, including:
An employee should be ready to present a case for their workers’ compensation appeal. You must prove that your injury happened on the worksite or during your working hours and that your workplace injury caused your disability, and now you need medical care.
You must prove causation to win a workers’ compensation claim or an appeal. Causation is the most challenging part of a claim to prove. Employees must show that their injury happened in the course of their employment, which is easier in some cases than others.
It is often difficult for employees to prove claims on their own. Attorneys with experience in workers’ compensation law know they need to connect the facts of your claim to your work and have experience doing just that.
When to file a workers’ compensation appeal is a strategic decision.
A lawyer can file a worker’s compensation claim appeal if:
Unfortunately, not every worker collects on their workers’ compensation claim. There may be several reasons that an employee does not receive the benefits they may deserve after an injury.
Workers’ compensation is a form of insurance. Your employer’s insurance provider will work to avoid paying out any claims to protect the insurance company’s profit margin. In worker’s compensation cases, insurance companies will try to use technicalities to avoid paying you, like missed deadlines or failing to complete a specific form.
The most common reasons insurance companies deny workers’ compensation claims include:
Reopening a workers’ compensation claim is different from an appeal. There are some circumstances where reopening a case is the more appropriate option.
You may consider reopening your workers’ compensation case if any of these circumstances apply:
A workers’ compensation attorney can help you build your case for benefits. An attorney can help you protect your legal rights even if insurance companies or employers try to deny your legitimate claim.
Many claims receive a denial because of a technical error. Many technical errors are simply due to missed or incomplete paperwork. Having an attorney working on your behalf eliminates the risk of missing out on your benefits because of missing a deadline or submitting incomplete paperwork.
A workers’ compensation attorney can help you negotiate with your employer’s insurance provider. Your attorney can help you understand your claim’s value, manage your compensation expectations, and pursue the financial recovery you need after a workplace injury. With your attorney’s help, you can reach your goal of financial recovery from an injury.
You may need to proceed to a hearing if you cannot reach a fair settlement offer from your employer’s insurance company. Your attorney can help you prepare for how the case will progress and what you should expect at the hearing.
Finally, your attorney will represent you at the hearing or trial of your workers’ compensation claim. It may be intimidating to stand in front of judges telling your story and making your case on your own. A workers’ compensation attorney can take that burden off you and help you tell your story effectively and persuasively.
You need a solid legal team in your corner as you try to get the compensation you deserve after a workplace injury. You have already suffered an injury and fought through an initial claims process, and now you have received a denial. Many people feel hopeless in this situation, but there are additional options to fight for your benefits.
With the right legal team working for you, you can put yourself in the best position to maximize your compensation after suffering an injury while on the job. If you received a denial of your workers’ compensation benefits, contact an attorney in your area immediately.
If you recently suffered an injury and need help filing your initial claim, a Workers’ Compensation lawyer can help with this process, as well. Never hesitate to seek assistance with an initial claim or if you need to appeal a benefits denial.
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