How to Appeal a Workers' Compensation Denial?

Workers suffer from mental stress when they receive a rejection letter from the insurer stating that their claim has not been cleared – this is to be expected since it rarely happens. If you work in a dangerous environment, worker’s comp is something that you should understand very well.

Often times the situation is frustrating because on one hand they are reeling from tremendous physical pain and have absolutely no idea when they will be able to rejoin their work team and on the other hand they have to pay for their own medical treatment. However, the sunny news is that they can appeal against the workers’ comp denial.

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Contact the insurer

To begin with, you need to contact the insurer immediately to know why the claim is denied. Often the reason for denial is included in the denial letter but it is always a stellar idea to speak with the insurer directly to clarify things.

Worker’s compensation lawyers say that often claims are denied because of filing errors i.e. forms might not be filled correctly or some documents may be missing etc. Insurers allow the claimant to redo the paperwork and resubmit them for clearance. This means that if an error is causing the hold-up you simply need to rectify it to be eligible to receive the benefits.

Your workers’ comp claim may be denied if the insurer believes that you are not eligible to receive the compensation. Worker’s compensation attorneys say that insurers might not want to pay claimants who are not injured in their place of work or during their duty hours.

This does not always make sense though or work. This rational does not always fit the code. Sometimes insurance companies need to be flexible. The case in point here could be Captain Phillips (Tom Hanks) who was injured in the safety boat of the ship and not actually the ship. The point is was he was still injured and it was not his fault he was on the rescue boat – he was forced there at gunpoint (now in real life it appears Captain Phillips was really a coward and how he was portrayed in the movie totally fiction but that is another topic). Phillips still should receive some worker’s comp for his psychological ordeal and physical injuries.

Futhermore, often rejections stem from a belief that the injury is a result of a pre-existing ailment. Though in such as case, you can always reach out to the insurer and ask them to reconsider. You can also provide more documents as evidence that the injury was sustained on the job.

File a formal appeal

The rejection notice will tell you how to file an appeal. Appeals must be filed within the stipulated deadline which varies from state to state. In many states you can file within a year of receiving the notice while in other states you are required to file an appeal within weeks. Procedures of filing are also different. In some states you only have to send a letter to the worker’s compensation agency. In others there are specific forms that must be filled and submitted along with several documents.

Mediation

In many states workers are required to attend mediation before the hearing. The meeting is held in a conference room where the worker, his or her lawyer, insurer and their lawyers appear before a neutral third party and present their respective cases and evidence. During this stage you must have a legal pro who will help you understand the legal issues and present your case before the mediator. This is an informal gathering and if a solution is reached you are not needed to attend the hearing.

The hearing

Worker’s compensation lawyers point out that hearings are not as formal as a trial but the basic principle is the same. Basically you have to appear before an administrative judge and present your evidence in a formal setting. You can be questioned by the both side’s legal counselors (one of them is your own of course) and you are expected to answer truthfully as you will be under oath. Both legal representatives will also question witnesses and make their arguments to validate their stands.

At the hearing you will have to prove that the insurer was wrong to deny your claim. If the insurer insists that your injuries were minor, you will have to provide testimonials of doctors or show reports to establish that you have actually suffered severe injuries.

If you are denied once again then you can file a second appeal. In the event this appeal too fails you have to file a lawsuit against the insurer.

If your workers comp claim has reached a road block or has been denied, make sure to contact a workers’ compensation lawyer immediately and allow your litigator to commence negotiations so that the insurer is forced to take notice.