You should not lose hope if your employer or its workers’ compensation insurer denies your initial claim for benefits after an accident or illness on the job. Unfortunately, many deserving claimants need to go through the appeals process to get the benefits to which they are entitled. You should review the letter that notifies you of the denial, which will describe the basis for the denial. Sometimes the problem can be easily fixed. For example, you might have forgotten to submit required documentation, or the insurer might have made a mistake. You might be able to address the error with the adjuster for the insurer. If the situation involves more than a minor mistake, though, you probably will need to file an appeal.
Possible Reasons for Denial
Like any other insurer, workers’ compensation insurers are profit-based companies driven by their bottom lines. This gives them an incentive to deny a claim whenever possible. Insurers deny many claims on the basis that a worker’s injury was not related to their job, as is required to receive workers’ compensation benefits. This might involve arguing that a pre-existing condition caused your injury or that you were not actually working at the time of an accident. To bolster your position in an appeal, you may want to gather further medical documentation about your condition. This could include an independent medical examination if your insurer does not accept the opinion of your treating doctor. You also may want to introduce testimony from witnesses who saw the accident. They could confirm that you were performing your job duties and were not engaging in misconduct.
Common Reasons for Denial
The injury was not related to the worker’s job
The injury or claim was not timely reported or filed
The right to benefits is restricted because the claim involves a mental or emotional condition
The condition is not as severe as claimed
Other denials may arise from procedural problems. The insurer may argue that you did not report your injury to your employer or file your workers’ compensation claim within the required deadlines. There are very few exceptions for missing these deadlines. If your employer actually knew about the injury or illness, however, your claim may survive a failure to formally report the injury.
Complex conditions may pose more difficulties in receiving benefits. If you are suffering from a mental illness caused by your job, or if your condition resulted from emotional stress, your right to benefits may be restricted. The insurer also might argue that your condition is not as severe as you are claiming, especially if it is not visible or medically straightforward.
Filing a Claim After Leaving Your Job
The general rule is that you cannot bring a claim for workers’ compensation benefits after leaving your job. This is true regardless of whether the employee or the employer ended the relationship. However, you cannot be fired because you reported an injury to your employer. You may have a right to benefits following a retaliatory termination. Many states also provide exceptions for an injury that the employee reported before they left the job or for an injury that the employee suffered while they were still at the job but after they gave or received notice of their departure.
Appealing a Denial
Each state provides its own set of procedures for appealing a denial of a workers’ compensation claim. You may need to start by pursuing an appeal through the administrative process, which may involve a hearing before the state board of workers’ compensation. Ultimately, you may be able to take your claim to state court. You will need to take action within a short period to preserve your right to an appeal.
While you may not need an attorney to file your initial claim, you probably would benefit from retaining an attorney to help you contest a denial. The attorney can help you collect many forms of evidence and present them in a persuasive manner. Mistakes made early in the appeals process can permanently damage your case at later stages of review. An attorney can help you avoid these missteps through their superior knowledge of the system.
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