Workers’ Comp Claim Denied: What to Do Next

More than 2.8 million Americans are injured on the job site every year. That does not include the more than 5,000 fatalities. Unfortunately, these numbers have increased over the last few years.

Many of these individuals find recompense through workers’ compensation, although some get denied. There are many reasons for this.

If you have had a workers’ comp claim denied, do not give up hope. The information below lays out the steps to take to get your case appealed. Keep reading to find out how to get compensation for you or your loved one’s injuries.

What Is Workers’ Compensation?

Workers’ compensation is an insurance policy that employers attain. It kicks in when an employee becomes injured on the job or as a result of a workplace condition.

Workers’ compensation pays cash benefits related to various types of injuries or illnesses sustained from a workplace incident or environment. It also pays death benefits to families of an employee killed on the job or from an illness related to a workplace environment.

All states demand that certain businesses carry workers’ compensation insurance. However, the details vary among locations

Each state processes workers’ compensation claims, usually under the direction of a board. It determines claims based on information submitted by the injured party and/or the employer.

For instance, Georgia law requires that all businesses with three or more workers, including part-time staff, must have coverage. There are exceptions for contract employees, which is typical among states.

What Does Workers’ Comp Cover?

Common workplace injuries include slips and falls, as well as injuries from equipment or machines in the workplace. It includes injuries related to workplace vehicles and equipment. Lacerations, burns, or harm from electrical components or appliances, as well as chemical exposure, are other common examples.

The amount received depends on the cost of medical care and ongoing rehabilitation. If the injury or illness resulted in the loss of earning potential, then those wages or salaries would be factored in.

Why Is a Workers’ Comp Claim Denied?

Appealing a workers’ comp claim denial depends on the reasons behind the initial decision. There are several common ones.

One is that your employer or the insurance carrier alleges that the injury did not occur on the job site. Another common reason is if your employer insisted that they were not notified of the injury within the requisite timeframe. Another cause for denials is failure to file the claim with the insurance agency during a specified period.

Often, a workers’ compensation claim is denied based on the grounds that a preexisting condition, rather than an accident, caused the injury. They also might claim that no one witnessed the injury take place.

Other rationales for denying claims include those where the worker contributed to the injury. This includes being under the influence of drugs or alcohol or engaging in horseplay on the job.

How to Fight Claim Denials

The strategy for appeal depends on why the workers’ comp claim was denied. However, the appeals process is similar, regardless of the reasons. Here are the basic steps you should take.

Contact an Attorney

The first–and most important–step is to seek legal advice. An attorney with experience in workers’ comp cases can assess your claim and make a determination on its validity. They can explain what rights you have and direct you throughout the appeals process.

Review Denial

The next step is to review the information in the denial letter. This will allow you to build a case that specifically addresses the reasons for denial. The letter also will likely supply information about appeals (or other) deadlines.

Gather Evidence

The next phase involves gathering evidence to support your claim. This often includes medical records and incident reports.

It could entail witness statements and other evidence, such as email correspondence, that are crucial to the appeal. This is why it is so important to retain anything you feel may be relevant to your case.

File an Appeal

Once you have an idea of the type of appeal you will make, you can officially file the case. Remember, it must be within a specific timeframe and include documentation that details evidence that supports your claim.

Attend Hearings

Depending on where you live, hearings can take several months to schedule. These are a chance for you to present your case, including additional evidence that supports your claim.

In some instances, out-of-court mediation is used to resolve the appeal. The goal of these proceedings is to reach a resolution without a formal trial. It also allows both sides to present their case, with an assigned mediator overseeing them.

What Determines the Appeal Outcome?

There are many different aspects of a workers’ compensation appeal. Therefore, myriad things can influence the outcome. A very common one is new evidence.

A good example is a claim denied based on the grounds that the employer was not notified of the injury in a timely manner. If you can produce an email that informed them or a witness-such as a coworker or human resources officer-who was present when you reported the injury, that could be enough to overturn the original decision.

There are more complex scenarios. For instance, it may be difficult to prove that certain illnesses are the result of workplace conditions. These cases usually require the testimony of medical professionals who can attest to the likely causes.

Regardless of the complexity of circumstances surrounding the injury, do not despair. If you can present adequate evidence to refute the reasons behind the denial, then your appeal will be granted.

Get Help With Your Workers’ Comp Denial Appeal

Now that you understand what to do if you have a workers comp claim denied, you can proceed with confidence. Remember, hiring an experienced attorney can help ensure the best possible outcome for your workers’ compensation lawsuit.

At Hollington Brown, we have more than 27 years of experience representing people who have been injured at work. We pride ourselves on providing expert legal advice for navigating the complex judicial system so that our clients get the compensation they deserve. Reach out to us today to set up a free consultation to discuss your case.

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