Even if you face a workers’ compensation claim denial, you may still be able to get compensation for your injury. The majority of claims that are denied end up being converted to paid claims. Even better news is that, on average, the amount awarded for converted claims is higher than the original claims.
Many employees despair after their claims have been denied, believing that they have no other options. If you are an injured worker who has experienced a workers’ comp denial, The Law Office of William L. Phalen is here to help you recover the compensation you deserve.
Understanding Why Your Claim Has Been Denied
Claims can be denied for numerous reasons, but this does not mean you have to give up. If you partner with an experienced workers’ comp lawyer, you may be able to recover the compensation you deserve for your injury or illness. The following are some of the reasons why your workers’ comp claim may be denied:
1. You Did Not Immediately Report Your Injury
One reason your workers’ comp claim may be denied is if you do not immediately report your injury after the accident occurs. If you do not report the accident and injury as soon as it happens, an insurer may assume you were not actually hurt.
Additionally, under the workers’ compensation laws in many states, you are required to report your work-related injury within a short period of time. Waiting to report your injury can only make recovering compensation more difficult, so if you are injured at work, report it immediately and complete an accident report. These steps can ensure you are complying with workers’ comp laws and increase your chances of receiving benefits.
Look up the laws in your state so you know how many days you may have to report your injury. Missing deadlines can mean your claim is denied.
2. You Did Not Seek Medical Attention
After immediately reporting your injury, you should seek medical attention as soon as possible. Failing to request or seek medical attention can make it more difficult to prove you were injured seriously enough to require workers’ compensation benefits.
For most workers’ comp cases, you should receive medical treatment to recover compensation for your injury. If your injury does not require treatment, it may not be serious enough to warrant workers’ comp benefits.
3. You Have No Witnesses
Many workers’ comp insurers do not like unwitnessed injuries and may deny your claim as a result. If no one witnessed the accident that caused your injury, most insurers are likely to question it.
While you cannot control whether there are witnesses to your accident, you can still support your claim by reporting your injury to your supervisor and co-workers immediately. Ensure you are reporting the same information to each person about how your injury happened.
4. Your Accident Report and Medical Records Differ
If your statements about how your injury occurred are not consistent with your initial medical records, the insurance company may deny your claim. For example, if you tell your supervisor about how the accident took place, but you tell your doctor a different story about how the accident occurred, this will hurt your workers’ comp case and may even get your claim denied.
To avoid this, ensure that when you tell your supervisor, your co-workers, your health care providers and your HR office about the accident, you are consistent.
5. You Were Fired Before You Filed Your Claim
If you wait until you are laid off or fired to file a workers’ comp claim, your claim may be denied. An insurance company may view your claim as a revenge tactic rather than a legitimate claim. As such, you should file your claim as soon as possible after sustaining your work-related injury.
If your employer fires you before you can file your claim, you may have a difficult time recovering compensation and convincing the judge and insurer that you have a legitimate work-related injury. To avoid this, ensure you know the filing deadline to make sure you are filing your claim on time.
6. Your Injury Is Disputed
Your claim may be disputed by your employer or the insurer for a variety of reasons. For example, your employer may allege that you were engaging in illegal activity or horseplay at the time of the accident. Your employer may also classify you as a contractor to make you ineligible for workers’ comp.
If you were intoxicated or using drugs at the time of the accident, your claim will likely be denied. The presence of these substances may be detected if you are taken to the emergency room following the accident and your medical records show the substance was in your system. In this case, the insurance company will almost certainly deny workers’ comp benefits.
Your employer or the insurer may also claim that your illness or injury is not as severe as you have stated and may argue that there was no reason you needed to miss a shift or see a doctor.
7. Your Employer Alleges Your Injury Is Not Work-Related
If your employer alleges that your injury occurred outside the workplace or is not work-related, your claim may be denied. For example, your employer may claim that your injury took place while you were on your lunch break off company property or that your injury was preexisting. This can make work-related repetitive stress injuries difficult to prove. Your workers’ comp claim may also be denied if your employer accuses you of exaggerating or fabricating your injury.
In this case, you may want to obtain additional evidence and another medical exam to help prove that your injury is work-related.
8. You Refused to Give a Recorded Statement or to Sign a Medical Authorization
The insurer may request a recorded statement from you in which you describe your injury and the accident. Unfortunately, if you do not have an attorney, giving a recorded statement generally will not help you. You are also not legally mandated to provide a recorded statement to the insurer.
When an insurance company requests a statement, this is often a sign that they have an issue with your case. If you give a statement, the insurer may deny your workers’ comp benefits. However, if you refuse to provide a statement, the adjuster may claim that your failure to do so prevented the insurance company from offering benefits.
Additionally, an insurer may ask you to sign a medical authorization. This allows the insurance company to communicate directly with your doctors to obtain your medical bills and records. As with a recorded statement, you typically do not have a legal obligation to sign a medical authorization. If you sign a medical authorization, an insurer may invade your privacy by obtaining medical records unrelated to your work accident.
While you do need to give your medical bills and records to the insurer when you are filing a workers’ comp claim, you can fulfill this obligation by instead obtaining your records yourself and sending them to the insurance company. However, the insurer may be displeased if you choose this route, as they prefer to obtain the medical records and may not trust that what you are sending is the complete file.
If you are being pushed to sign medical authorizations and you do not want to sign one, reach out to a workers’ comp attorney who can deal with the insurer on your behalf.
Appealing After a Workers’ Compensation Denial
Persistence is key. Just because your claim got denied does not mean you cannot appeal the denial. Your denial letter should include a deadline by which you can file an appeal. State law determines this deadline. The following are steps you can take after a denial:
1. Try to Resolve the Dispute With Your Employer or the Insurer
Before you initiate a workers’ comp appeal, you may want to schedule a meeting with your employer or the insurer to see whether you can easily resolve the dispute. This may be possible if the workers’ comp claim denial is due to a simple misunderstanding or a clerical error.
2. File an Appeal
If you would still like to pursue a workers’ compensation appeal, you may want to hire an experienced attorney who can handle this often-complicated legal process. At this point in the process, your employer is likely not involved in the matter and the task is entirely yours to handle. This is why many employees who are filing an appeal choose to hire an attorney who can file on their behalf and successfully navigate the process.
3. Request a Hearing
Though the specific appeals process varies from state to state, a hearing is often involved either through the state workers’ compensation appeals board or the labor department. In Kansas, this hearing will take place before the Division of Workers’ Compensation. Under state law, you need to seek a hearing within two years after you receive your last workers’ comp benefits payment or within three years after your accident or injury, whichever is later.
If you want to request a hearing with the board, you must submit a Notice of Intent to either your employer or the insurance company and allow a week to receive their response. In your letter, you will explain why you are seeking these benefits. If you are unable to resolve the issue with your employer, you can request a hearing by completing an application for a preliminary hearing, along with your Notice of Intent and documentation.
4. Prepare for Your Hearing
If you will be participating in a hearing before the workers’ comp appeal board, bring any relevant documentation with you. The documentation you provide should address the reason your claim was denied, such as a timesheet that shows you were indeed working when you sustained the injury and your medical records related to your injury. If you obtained a second medical examination, be sure to bring that record.
Hiring an Attorney to Guide You Through the Workers’ Compensation Process
Whenever you are in a dispute with an employer or insurance company, you may want to hire a lawyer for legal representation. To challenge the employer’s or company’s position, you will need evidence that proves your case. Hiring an attorney can help you avoid making mistakes during the process and instill confidence in your decision-making moving forward.
Filing an appeal after a workers’ comp denial can be complicated. You may be unfamiliar with many of the administrative rules, and preparing for and participating in the hearing can be much easier with a workers’ comp attorney at your side. Appealing a denial often requires that you use legal tools to collect evidence, file formal paperwork and present your case before a board during a hearing.
Beyond a claim denial situation, you may want to hire a workers’ comp lawyer in the following situations:
- Your benefits are delayed.
- Your symptoms develop gradually.
- Your injury is long-term or permanent.
- You have a claim against another party.
- You suffer from a preexisting condition.
- You are uncertain what doctor you should see.
- You are unsure about the workers’ comp process.
- You have faced retaliation at work after filing a claim.
- You are unsure what may hurt your workers’ comp claim.
- Your employer says you are not covered under workers’ comp.
- Your employer disagrees with you about your ability to return to work.
- Your employer or the insurer requests an independent medical examination.
- Your benefits do not cover the entirety of your lost wages and medical bills.
- Your employer disputes the decision made by the state workers’ comp division.
Your settlement is likely to be higher when you have a lawyer on your side. Workers’ comp lawyers are familiar with the law, can successfully utilize several tools to build your case and understand how to negotiate.
Contact Phalen Law Firm for a Free Consultation
Was your claim for workers’ comp denied? Trust The Law Office of William L. Phalen as your workers’ comp attorney in Kansas or Missouri. We have been working with clients in workers’ compensation for more than 30 years. We will assign a dedicated legal assistant or paralegal to your case, which means you will have a knowledgeable person to speak with every time you call.
At Phalen Law Firm, we handle every facet of workplace injuries, such as accidents, carpal tunnel claims, injuries following repetitive work, traumatic injuries and workplace fatalities. Contact us at Phalen Law Firm for a free consultation today.