The federal government requires most employers to provide sufficient workers’ compensation insurance in all U.S. states and territories. Workers’ compensation aims to protect employees from going bankrupt after sustaining work-related injuries. However, the reality is that the workers’ comp insurance system is very complicated to navigate.
Most employers purchase insurance from private insurers. This means that when you suffer injuries, the insurance provider, not your employer, will probably handle your workers’ insurance comp claim. The insurer will also be the one to decide whether to deny or approve your claim to cover your medical bills, wage replacement benefits, rehabilitation, and other qualified benefits.
Why Insurance Companies Deny Workers’ Compensation Claims
Although each state implements different rules and procedures for workers’ compensation claims, regardless of where you are employed, one thing is certain. Insurance companies will attempt to use technicalities such as specific requirements and deadlines to try and justify the denial of claims. The initial claim denial is a contentious issue in most workers’ compensation cases.
You need to understand that insurers will also be looking out for their best interests, which means limiting settlements or denying claims altogether. They will investigate claims for any opportunity to reduce settlements or deny benefits.
These are among the most common reasons insurance companies give when denying workers’ comp claims:
- The employee failed to notify the employer of the accident and injury
- The employee did not suffer injuries on the job
- The employee missed the deadline for filing a workers’ comp claim
- The employer is disputing the employer’s injury claim
- The employee was under the influence of alcohol and/or drugs during the incident that led to the injury
- The employee’s injuries are not serious enough to warrant coverage
- The employee’s medical condition does not fall under workers’ compensation coverage
- The employer laid off or fired the employee
You should also know that it’s illegal for an employer to fire an employee for filing a workers’ comp claim or reporting an injury. If this applies to your case, your employer has violated federal and state labor laws, which means that you can also consider filing a third-party claim against your employer, besides your workers’ compensation claim.
When to Appeal a Denied Workers’ Compensation Insurance Claim
It could frustrate and worry you to learn the insurer denied your claim. Fortunately, you have the right to dispute the denial and appeal your claim. The denial letter must specify why the insurer denied your claim, how and when you can file an appeal, and a deadline notification for filing the appeal. This deadline is crucial because missing it could result in missing your right to obtain benefits.
If you don’t fully understand the contents of the denial letter or don’t know how to proceed with the claim, consider consulting a workers’ compensation claim attorney in your area for proper guidance. Also, if you have clear evidence that the insurer denied your claim due to some irregularity, administrative error, or fraud, you can file a complaint with your state’s workers’ comp administrative office.
When to Reopen Your Workers’ Compensation Insurance Claim
Reopening a claim is different from appealing it. Denied claimants might consider reopening a previously closed claim in these scenarios:
- The injury worsened or returned
- The employee has new evidence to prove the claim and/or show that the compensation settlement was unfair or insufficient
- The lighter duties or job options the employer offered does not exist
- The employer found evidence of fraud or an administrative or legal error that resulted in an unjust denial
Take note, though, that each state sets a different deadline for reopening a closed workers’ comp claim. Insurance companies consider claims closed once the employee receives the final and full payment and signs the release. Likewise, the procedures for reopening denied claims vary from one state to another. Broadly speaking, it typically requires filing a request with the workers’ comp commission or board in your area. You need to get in touch with them for specific instructions and follow all the procedures or risk having your request to reopen your claim denied.
But what if the statute of limitations to reopen your workers’ comp claim lapsed? The nature of most injuries can make verifying the worsening or aggravation of previous injuries hard to determine, resulting in delays. Insurers will always dispute reopening closed claims based on time limits to avoid settling the claim and compensating the claimant retroactively. It is important to act swiftly and contact a workers’ compensation attorney immediately if you think you need to reopen a past claim.
When to Request a Hearing
You can request an administrative hearing to resolve disputed workers’ comp claims, such as claims denied without clear or valid reasons. But you can likewise request a hearing if you want to dispute some of the decisions made by the insurer about your ability to start working again, weekly wage benefits, permanent disability benefits, or vocational training, among others.
When you request a hearing, you take away the power of your employer’s insurance provider and hand it over to the workers’ comp administrative judge. However, it will also be up to you to effectively argue your case. You’ll need to look up relevant employment and labor laws and show your medical records to support your claim. You will also require copies of relevant files from your employer and the insurance provider. But take note that you may need a subpoena to get ahold of files from the insurer and your employer.
A workers’ compensation lawyer can handle all of these tasks for you.
Get Legal Advice from an Experienced Workers’ Compensation Claim Attorney
If you have yet to consult a workers’ compensation claim attorney, this is the time to do so because the insurance provider will surely send their attorneys to defend their case. While you can file a workers’ compensation insurance claim on your own, if the insurance provider delays your claim unnecessarily, denies it based on unfair grounds, significantly cuts your benefits, or you’re facing an administrative hearing, seek legal assistance. Contact a workers’ compensation attorney to discuss your options today.a