Not all workers’ compensation claims are accepted upon the first submission. Many times, the first request is denied, and the claimant will then need to figure out what to do next. Does that person appeal, or should he or she accept that first denial? We have asked attorney, Alaina Sullivan, and here is what she had to say: What Are the Grounds for Denial? That brings the initial question of why the workers’ compensation claim was denied. One of the most common reasons for denial is the claim was not reported or filed within required time limits. Under the law, the worker must report the claim immediately, which can often be in a number of days. The employer is then required to inform the state and/or the workers’ compensation insurance carrier quickly, as well. If the claim is not submitted in a timely manner, this can result in a denial. Another common reason is that the employer disputes the submitted claim. The reasons for the dispute could be the employer is disputing that the accident happened at work or that the employee’s injury or illness is a result of this accident while on-the-job. The claim may also be denied due to certain restrictions put on by the state, such as injuries caused by stress-related conditions. In addition, the injuries may not be serious enough to necessitate a claim. The denial letter will detail the exact reasons for why the claim was denied, and this will help the injured employee decide how to proceed. How to Appeal the Workers’ Compensation Denial The letter that the injured employee receives regarding the denial will then dictate how he or she makes the next step. The letter will describe how the denial can be appealed, so it is important that the employee thoroughly reviews the letter before making any decisions. It is recommended that the employee first contact the employer or the workers’ compensation insurance carrier to discuss why the claim was denied. If the denial was given because an error was made in the paperwork, that can be cleared up pretty quickly if the mistake that was made was a genuine error on the part of the employer or the insurance company. If employer disputes the claim, the employee will need to do additional discovery to get evidence to support his or her workers’ compensation claim. The employee may need to gather eyewitness accounts of people who saw the incident or expert witnesses, as well as medical records to support the claim. Each state handles workers’ compensation appeals in a different manner. Therefore, it is important that the injured employee consult his or her state’s laws to see what procedures are needed. Normally, the first level of appeal involves an administrative hearing before an administrative law judge (ALJ). This appeal hearing can be through the state’s labor department of the state’s department or board of workers’ compensation. Other states have different levels for injured workers looking for an appeal. What Happens at the Appeal Hearing? Every state differs in how the hearings are handled, but normally, the injured employee will be able to present proof that 1) he or she was, in fact, injured on the job and 2) the injuries are permanent and a direct result of the injury. This will normally involve submission of medical evidence, as well as testimony from those who witnessed the accident resulting in injury. While an administrative review hearing is not as formal as a hearing before a state court, administrative hearings often do have formal procedures for submission of evidence and testimony. At many times, it is a good idea to have an attorney assist the injured employee in presenting the case before the administrative hearing. If the individual loses his or her administrative appeal, appealing to a higher level can be even tougher and the costs that much more. It helps to have an attorney handle the appeal at the lower level rather than bringing him or her in at the second level when that could have been avoided with the proper submission of evidence at the first appellate level. Contact an Attorney Today If you are in the process of pursuing workers’ compensation, have received a denial of your first claim and have questions about whether you appeal, a workers’ compensation attorney can help review your case and discuss your options. An attorney can listen to the facts of the case and can best advise you on how to proceed. Contact an attorney experienced in social security disability to schedule a consultation today. Additional Resources Denied by Insurance? Workers' Compensation Denial By State
