If you were injured on the job or developed a medical condition because of your work (cumulative trauma like a repetitive strain injury (RSI) you are probably hoping to receive workers’ compensation benefits. Workplace injuries are generally covered by your employer’s workers’ compensation insurance. Many states require employers to be covered in accordance with the average level of risk for that particular industry. What can you do if your claim has been denied? You may be able to appeal your denial through your state’s board of workers’ compensation.
Employers or their insurance companies sometimes look for any possible reason to deny workers’ comp claims. The first thing you need to do is determine the reason why your claim was denied. The details should be explained in your denial letter. In New York State that form is called a SRO 1-04. If you believe your denial was done in error you can appeal.
Common Reasons for Denial of Workers’ Comp Claims
Your employer may say that you weren’t working when you were injured, or that you were involved in some sort of horseplay or misconduct, or that your current medical condition is not a direct result of an accident at the workplace. Whatever your reason for filing the workplace injury claim, you will need to gather sufficient evidence to support the claim. Some examples include, witness testimonials, or medical evidence and records. If the doctor that is treating you has already stated that your current condition was due to an injury at work, but your insurance company disagrees, you may need to get schedule another medical evaluation to get an additional doctor’s opinion.
The law in your state may have special restrictions on workers’ comp claims for increasing trauma or psychological conditions. Some states rule out workers’ comp benefits for illnesses caused by long-term stress at work.
In most cases, you must receive medical treatment in order to receive workers’ comp benefits. If you deny or do not seek out medical treatment your claim may be denied. When you discuss the extent of your injury with your employer, they should pull out the employee handbook to review their policies and procedures. Employees that initially report the injury but refuse treatment may see that their workers’ compensation benefits are suspended. Your employer may not allow you back at work until you pass a medical clearance test to determine if you can perform your everyday duties.
Timing is everything when it comes to filing a workers’ comp claim. You should immediately report your injury with human resources and make it clear that you were hurt on the job. Check with state laws to see what your timeframe is to file your workers’ comp claim. If you did not adhere to the state laws, your claim could be denied. This goes for both reporting your injury and filing your claim in time. Many states include limited exceptions for when the injured employee couldn’t file a claim right away because they were in a coma, severe injuries that required immediate and prolonged treatment or surgery (burns) or the employee had to remain quarantined. Don’t hesitate to file a claim even if your injury seems minor. It could get worse as time goes on especially if you have neck or back injuries. If you happen to file a claim and the injury gets better on its own, the claim will be closed but if you wait to file you could lose the chance to get benefits or risk the claim being denied.
Have you recently quit, been laid off or fired from the job where you filed your workers’ comp claim? Insurance agencies usually deny claims that were filed after you left the company. Did you report the injury while you were still employed there or during the time that you gave your notice? Some states have special rules for workers’ comp claims that were filed after you left your job. If you qualify for one of these exceptions you may be able to receive workers comp.
So Your Claim Was Denied, Whats Next?
Don’t feel like you won’t be receiving workers’ comp benefits just because your claim was initially denied. Double check and reread the letter that was sent to you saying that your claim was denied. The reasons should be listed but if you feel that it had to do with paperwork or a similar mistake, you should contact your claims adjuster and employer to explain your situation. In most cases you will have to consider appealing the denial. Your letter should give a deadline for filing your appeal, which is determined by state law. The first level of the appeal will be a hearing where you will have to provide medical and any other type of evidence that supports your claim in front of an administrative law judge. The hearing can be done through your state labor department or state board of workers’ compensation.
If you still want to appeal the decision, you should look into getting a workers’ comp lawyer as soon as possible. A lawyer will help you determine whether or not an appeal would be the best route. Since the deadlines for workers’ comp are short you don’t want to miss out on receiving your benefits because you we’re late. You will want to bring any documentation, medical records and reports that state your case to your court date.
If you have any questions about your workers’ compensation claim or would like more information, call Losi & Gangi at 716-854-1446.