Worker Compensation Claims Appeal

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In most states, when you are injured on the job, you cannot bring a standard personal injury lawsuit against your employer. If your employer has workers’ compensation insurance and you are a covered employee (not an independent contractor or otherwise exempt) then your only opportunity to recover damages is with a workers’ comp claim.

Workers’ comp claims are designed to cover your medical costs and to pay your lost wages if you are temporarily or permanently unable to work. If your workers’ comp claim is denied, you may be unable to recover these losses. Therefore, if you file a workers’ compensation claim that you believe is unfairly denied, you need to appeal the denial of benefits.

Denied Workers Compensation?

After you file a claim with your employer’s workers’ comp insurer, you will get a decision from the company on what benefits you are entitled to. In some cases, this decision will be a denial letter stating that you are not entitled to any benefits.  If you receive a letter denying benefits, then you should read the letter carefully to find out how long you have to appeal the denial. Make sure you appeal the decision within the timeframe specified in the letter.

Sometimes, even if the claim is not denied, you may want to appeal. Some insurance carriers will both deny and accept a claim. This means they will accept your claim for one or more of your injuries, but deny it for others. Often, you still want to appeal this decision in order to fully recover medical bills and lost wages related to all injuries you incurred. Since you have to appeal this partial denial within a set period of time, you may lose the opportunity to do so.

Workers Compensation Appeal Process

You may want to speak with the insurer who denied your claim first to see if things can be resolved before appealing. Find out the specific reasons why your claim was denied and if the issues are resolvable, such as missing paperwork, see if the insurer will reconsider your claim before filing an appeal.

Once you decide to file an appeal, the process varies by state. Most states require you to file a formal appeal within one to three years after the denial of benefits. In many states, an Administrative Agency or Advisory Board has taken over the process of hearing appeals. This means that instead of going to court, you will go before some type of Committee or Board that specializes in Workers’ Compensation claims. 

The specific process of appealing also varies by state. Some states (Texas, for example) require a “benefits review” conference to be conducted after the denial. This can involve a review of your documentation of injury and doctor’s examinations. If the disputed issues can’t be resolved in the benefits review conference, only then is a hearing conducted. Witnesses are presented at the hearing and you get to testify before a government board that will make a decision on whether the insurance company’s denial of benefits was valid.

In other states, like California, workers’ compensation judges usually hear appeals first. You may be able to present witnesses and experts at this hearing. If the issues are still not resolved, then the Worker’s Compensation appeals board hears the case.

Reasons for Appeals

There are a number of possible reasons a claim might be denied that can be litigated in appeals. Some common reasons for denial of benefits include:

  • Type of injury: If you are not specific about your injury, your claim may be denied. Certain types of injuries, such as slip-and-fall injuries, are also often greeted with more suspicion
  • Pre-Existing Condition Issues: If you had a pre-existing condition, your employer may argue that the injury was caused by the condition instead of by the work related injury
  • Questions about whether the injury arose out of employment: The injury had to have occurred because of the job in order for you to recover.  In some cases, it may be unclear whether a job related activity actually caused the injury.
  • Question about whether the injury arose at work: This issue can come up if you were injured on the way to work or during your commute.
  • Proof of Disability:If you are asking for temporary or permanent disability, the medical document(s) must conclusively prove that you have been disabled as a result of your injury and that the disability is severe enough to preclude you from working.

Workers Comp Appeals: Information by State

If your state is not yet added, come back as we are always updating this information.

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When To Involve a Lawyer

You should involve a workers’ compensation attorney as soon as you receive a denial of benefits letter. Since the appeals process varies by state, it is essential that you understand the appropriate course of action to take within your jurisdiction. This is vital because if you wait too long to file your appeal or do not use the appropriate procedures, you can forfeit your opportunity to recover under worker’s compensation.

Finding Legal Help

You should hire an attorney with experience in worker’s compensation litigation. In many cases, the attorney’s fees are established by State Worker’s Compensation laws and can be paid as a part of your worker’s compensation settlement. Find a qualified attorney who can provide you with assistance in filing your appeal and who has a strong background in worker’s compensation appeal hearings.

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