What If My Workmans Compensation Claim is Denied?

Worker's compensation is a program designed to help both employees and employers when an on-the-job accident occurs and injures and employee.  Worker's compensation is an insurance program that protects workers by providing coverage for medical expenses and loss of income when there is an accident or some form of involuntary health related job layoff.  It protects employers also as they could be held responsible for accidents on the job, it prevents civil lawsuits in such cases where injuries are incurred.  Benefits for permanent disability can also result in a lump sum payment for lifetime benefits.  Filing claims for these benefits must be done so quickly by both the employer and employee.  The system can be complex and confusing and even more so if the claim is denied.  There is, however, an avenue for recourse in such cases.

Disputing Denied Claims

When a worker's compensation claim is denied, the claimant is sent a letter explaining why his claim was denied.  The worker has the choice of replying to the denial and requesting that his claim be reconsidered; however, unless he provides additional evidence to support his claim, it will more than likely be denied again.  It is also possible for the claimant to request a hearing before the administrative law judge with the State Board of Worker's Compensation.  But, once again, without additional supporting evidence strengthening his case, the claimant will probably be denied again.  Most people prefer to employ an attorney at this point to help them prepare the strongest case possible.

Reasons for Denial

There are many reasons a worker's claim for compensation might be denied.  One that happens quite often is that the claim is filed after the state's time limit for a worker's compensation claim to be accepted.  It is also possible that if the claimant didn't receive medical treatment for the injury received on the job that the case is lacking an important piece of evidence that would otherwise qualify him for the claim.  Lack of documentation throughout the case could also be a big problem.  For example, if the employer didn't record the incident correctly, or the claimant failed to complete something, even throughout the medical treatment process, it is important that records be kept and that the claimant receive copies.  The more serious the injury, the more documentation a person should try to obtain.  The last potential reason a claim could be denied is that there is proof of some pre-existing condition which strongly suggests that the injury received in the workplace was not the result of an accident, but the natural result of the condition already present.

What to do if Claim is Denied                      

Many ask themselves, what if my workman's comp claim is denied?  Fortunately, if that should happen, there are some steps that can be taken.

  1. First, retain an attorney; one who specializes in worker's compensation law.  Lawyers are trained to negotiate with insurance companies in your behalf.  They already know the relevant laws regarding labor and how they apply to the state regulations where you live. Also, the attorney's fees are usually taken from the final settlement as a percentage of the benefits you win after the litigation process.
  2. Second, keep a file.  Request a copy of your personnel file; it should contain the report you completed when you were injured or your illness occurred.  Remember the claim must be made as soon as possible.  Get a copy to the insurance company as soon as possible and keep a copy for yourself.
  3. Third, evidence for your file.  Include medical records and other evidence that supports your claim.  Narrative reports from your doctor, test results, emergency room reports, rehabilitation progress reports on you injury and recovery, all would be supportive of your claim.  If there are witnesses, be sure and get written statements from them.  Also track your personal medical expenses during this time, including transportation to medical appointment, prescription costs, etc.
  4. Fourth, attend the hearing.  It is here that you will be before a judge or mediator.  Testify truthfully of the details of the accident, the nature of your injuries and the lost wages, and expenses incurred due to this accident.
  5. Fifth, do not get in communication with the insurance company.  If they try to contact you, refer them to your attorney.  If you receive any kind of correspondence from them send it immediately to your lawyer. Do not respond to it yourself.
  6. Sixth, the insurance company will observe you in public, probably recording your actions with a video camera.  It you are seen exercising or engaging in any physical activity that undermines your claim it can be used against you to deny your claim.  They can even use it to pursue you in court for fraud.

Employ the Services of an Attorney

In cases of this sort, an attorney will be the best step you can take.  His services will be invaluable to you in navigating the complex legal gauntlet you'll be required to run through.  He can also best prepare your case so that you can receive the support you deserve.

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