Here’s what you'll do now if your workers’ compensation audit is denied, or workers’ comp won’t pay the complete medical and wage replacement benefits you’re entitled to. Most employers are legally required to supply workers’ compensation insurance in every state and territory within us. Meant to guard workers against bankruptcy after a work-related injury, the workers’ compensation system is often a sophisticated nightmare for a few workers and their families.
In most states, employers purchase workers’ comp insurance from private insurance companies. When a worker is injured, it’s the insurance firm that handles the claim and approves or denies coverage for medical treatment, surgery, rehab, or wage replacement benefits.
How Workers’ Comp Is Supposed to Work
Assuming you’ve been injured on the work by a corporation that carries workers’ compensation insurance, taking the proper steps, within the right order will preserve your legal rights to lost wages, medical attention, and in some cases, even future pain and suffering.
Notify management immediately after an on-the-job injury. The sooner you notify your employer, the higher it'll be for you at the end of the day. If you’re rushed to the hospital with serious injuries, notify your employer as soon as your condition stabilizes.
Your employer should have a form for you to finish. If you’re too badly hurt to complete the claim form, have someone you trust completely the form for you. Fill out the form completely, accurately, and without exaggeration. Keep a replica of the shape for your records. Shortly after submitting your claim form, a representative from your employer’s insurance company will contact you. You may be asked to offer a recorded statement, either on the phone or face to face. Know what to observe out for when giving a recorded statement.
Depending on your state’s rules, after every week or two, you ought to be eligible for wage replacement benefits. You will typically receive about two-thirds of your base pay, up to the utmost weekly amount allowed for your location. Since workers’ comp wages benefits aren’t subject to federal taxes, many workers find yourself getting an amount on the brink of their regular wage.
Continue your medical treatment until your treating physician clears you to return to figure. Your workers’ compensation doctor will likely be recommended by your employer or your employer’s insurance firm.
Seriously injured workers may never recover enough from their injuries to travel back to figure, or to return their old jobs. Injured workers that suffer total or partial permanent disability will often be awarded a financial settlement toward future wage loss and offered vocational services.
Common Reasons for Claim Denials
While each state has different workers’ compensation rules and forms, regardless of where you're employed there'll be deadlines and requirements that the insurance firm can use to deny your claim. The initial denial of a claim may be a major issue in workers’ comp cases. Insurance companies are motivated to keep costs as low as possible. They scrutinize claims for opportunities to deny or reduce benefits.
These are some of the most common reasons your workers’ comp claim can be rejected:
Failure to Promptly Notify Your Employer of Your Injury
You must immediately (or as soon as reasonably possible) notify your employer of your injury. Under your workers’ comp coverage, your claim doesn’t begin until you report your injury to your employer. While each state has different time limitations, it’s usually about 30 days.
Missed Workers’ Comp Claim Filing Deadline
Reporting your injury and filing your claim are two different actions. There is a legal deadline for filing your workers’ comp claim, called the Statute of Limitations period.
Missing that filing deadline is grounds for denying your claim.
You Weren’t Hurt on the Job
To qualify for workers’ comp, your injury must happen while performing your work duties on your employer’s job site, or off-site while performing on an assignment from your employer or supervisor. If your injury occurs before or after normal work hours, or during a lunch break, your injury might not be covered.
You Were Under the Influence When Injured
Regardless of how hard you work, how long you’ve been employed, or what type of work you’re doing, if you are under the influence of drugs or alcohol when you’re injured, expect your claim to be denied. Technically, you don’t have to be fall-down drunk. If proof exists that self-ingested illegal narcotics or alcohol are even a little think about your injury, your claim will probably be denied. Even if you're under the influence of prescribed medications at the time of your injury, your claim could also be denied.
Your Employer Disputes Your Injury Claim
An employer may dispute your claim by arguing that your injury may be a non-work related pre-existing condition, it occurred outside of the scope of your employment, or that you’re faking your injury. As an employee, you're liable for proving why workers’ compensation should cover your injury.
Your Medical Condition Isn’t Covered
Some states don’t require workers’ compensation to hide soft-tissue injuries sort of a simple back strain or repetitive motion injuries, albeit the sprain or strain causes you to miss several days of work.
When it involves non-physical injuries, most workers’ comp insurance claims supported a psychological state issue that is denied initially. To be covered, you want to be ready to link your psychological state issues to a selected event, like a trauma you experienced while working.
Most states cover psychiatric injuries from specific events, such as post-traumatic stress disorder (PTSD). Even conditions arising over time, like depression and severe anxiety, could also be covered. It’s tough to convince an insurance firm your job duties caused your psychological state issues. You’ll need strong medical evidence, like detailed records about your condition from a licensed psychiatrist.
Your Injuries Aren’t Serious Enough for Coverage
What you think maybe a bad injury might not be considered as serious by your employer or the insurance firm. Your injury must limit or fully prohibit you from completing your job duties, and you would like to possess received treatment for your injury.
You may injure your back while loading boxes, but if the pain is merely temporary, your claim will likely be denied. Even if you think your injury is debilitating, you won’t convince the insurance firm unless you've got a doctor’s opinion to back you up.
You Were Fired or Laid Off
The insurance company will almost certainly deny a workers’ comp claim filed after you’ve been fired or laid off. You’ll have a hard time convincing the insurance company, or anyone else, that you’re not just trying to stick it to your former employer.
If you’ve been out on workers’ comp and the doctor has cleared you to return to work, you have to go back or risk losing your job and your workers’ comp benefits. You’ll need another doctor’s opinion to prove you are not yet ready to return to work.
On the other hand, if you’re fired in retaliation for reporting an injury, you should immediately contact a personal injury attorney.
Appealing a Denied Workers’ Comp Claim
Having your claim denied can be frustrating, but it doesn’t have to end there. You have a right to dispute the claim denial.
The denial letter you receive should include evidence of your workers’ comp coverage, when and the way you'll appeal the choice to deny your claim and notification of the deadline for filing your appeal. State deadlines are usually between 30 to 90 days. Missing the filing deadline for your appeal can end any possibility of getting compensation.
If you aren’t clear on the deadline, or you’re confused about the appellate process in your state, contact a workers’ compensation attorney for help getting the compensation you deserve.
Reopening a Workers’ Comp Claim
Reopening a workers’ comp claim is altogether different from appealing a denied claim.
The most common reasons to reopen a previously closed workers’ comp claim are:
- Your injury has returned, worsened, or become aggravated.
- The lighter alternate job duties or jobs no longer exist.
- New evidence is found proving your injury claim.
- New evidence shows the compensation award was inadequate or unjust.
- A legal or administrative error caused an unfair result.
- Fraud is discovered.
Each state sets time limitations for filing an invitation to reopen a claim. They can range from three to seven years from the date of your original claim denial – not the date of your original injury.
Some cases are considered closed when full and payoff is formed to you, and a release is signed. In these cases, neither you nor your insurance firm can reopen the claim.
The process of reopening a denied claim varies from state to state. It usually requires filing an application with the workers’ compensation board or commission in your area. Contact them and request the acceptable form and directions to reopen your claim.
Be sure to follow the rules set out in the form. You must state the rationale for your request and supply supporting documentation. You may need to include a copy of your denial letter.
Reopening Your Claim after the Statute of Limitations
Although legally possible, reopening a previously closed workers’ comp claim is extremely difficult. Most workers’ compensation commissions are already overloaded with claims and can search for any reason to refuse your request. Most state laws grant workers’ comp appellate judges great discretion in setting the statute of limitations period. Generally, judges define the statutory periods in favor of the claimant, especially when it has technically expired.
The nature of the many injuries makes determining the onset of aggravation or worsening of a previous injury tough to determine. Insurance companies always oppose reopening old claims, especially when there’s an opportunity they're going to need to pay not only the claim but also compensate you retroactively.
Request an Administrative Hearing
The insurance company is in no hurry to hand out money or benefits. Your claim may be denied upfront. If your claim is accepted, you'll need to dispute decisions made by the insurance firm when it involves your weekly wage benefit, ability to return to figure, vocational training, permanent disability settlement, or more.
If you afflict the insurance company’s decision on your worker’s comp claim, you'll request a hearing before the workers’ compensation board. Requesting a hearing takes the choice out of the insurance company’s hands and places it within the hands of an administrative judge. You’ll get to be able to argue your case, cite the relevant employment laws, and showcase your medical records in support of your claim.
Formally request copies of your employer’s files, your medical files, and the insurance company’s claim file. Your request may be denied without a subpoena. If you haven’t consulted an attorney by this point, now’s the time. You can make certain the insurance firm is going to be sending their attorney to the hearing to argue against you. Most workers can file their initial workers’ compensation claims on their own. However, when your claim is being unnecessarily delayed, your benefits are cut, or your claim has been unfairly denied, you’ll need expert legal assistance. It cost nothing to seek out out what an experienced workers’ compensation attorney can do for you.
