How does a workers compensation board make its decision?

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Question:

How does a workers compensation board make its decision?

Answer:

A workers compensation board is a state-created administrative agency designed to handle workers comp disputes. Workers compensation is the worker protection system initiated by legislatures from all 50 states. Those employees who are covered by workers comp- which is almost all of them- are ensured of payment for any work related injuries or illnesses that clearly derived from their job duties. As long as the employee did not expressly violate any company rules or the law (such as by being intoxicated when the injury occurred), the employee should be covered for his medical bills and lost wages, and should also have disability and other benefits paid. This is true regardless of whether an employer is in any way negligent or responsible for the illness.

When an employee makes a claim for workers comp, that claim will first be reviewed by the insurer for the employer. If this claim is denied at that point, the claim usually moves through an internal process of appeal with the insurance company. Assuming all these internal appeals re exhausted, it will then make its way to the workers comp board (or workers comp division or department as it may be called in some states).

Exactly what happens when the workers compensation board receives a claim will also vary by state. In some instances, a written appeal to the workers comp board is made first, while in other states, the board will decide all appeals to it by holding a hearing. 

Regardless of the exact procedure, the workers compensation board will make a decision on whether a workers comp claim is valid or not by:

  • Assessing all medical evidence. This may include asking the patient to undergo a specific exam or series of exams with an independent physician of their choosing
  • Reviewing arguments made by both the employee and the employer/insurance company

If you are going through the process of appealing a workers comp denial to the workers compensation board, hiring a lawyer is helpful. Your lawyer can assist you in understanding what the board will look at so you can do everything in your power to make sure your claim is a successful one.

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