If you work for an employer in Oregon, your employer may have taken out workers’ compensation insurance with the state’s own insurance fund, the SAIF Corporation. SAIF provides workers’ compensation in the event of a work related injury or illness and a successful claim will pay medical bills as well as a proportion of any earnings that have been lost while getting treatment or recovering at home. Not every claim is honored. From time to time, claims may be denied and if this has happened to you, it would be sensible to get help from a workers’ comp. attorney before proceeding with an appeal. The State Accident Insurance Fund – Company Profile Oregon is one of a few states in the U.S. that has a state owned insurance fund that provides discounted insurance cover to employers in the state, principally workers’ compensation insurance. SAIF, the State Accident Insurance Fund Corporation, to give it its full name, was established in 1914 by the state Legislative Assembly. Since 1980 it has specialized in workers’ comp. insurance. Its headquarters are in Salem, Oregon. Because of the cheaper premiums it can offer, SAIF provides coverage to 35% of Oregon workers. That means 600,000 employees working for a total of 50,000 individual employers across the state. How To Appeal A Denial If you suffered an injury while working, you will want to pursue a claim for workers’ compensation benefits. Many workers’ compensation claims are denied, and if your claim is denied, then you have rights and resources. You shouldn’t give up. If you have a legitimate claim, you are entitled to workers’ compensation benefits. You will want to appeal the decision so you can access the benefits and get your medical expenses covered. When your claim is denied, you will receive a notice of denial. This letter should explain why your claim was denied and how long you have in order to file an appeal. If you miss the appeal deadline, you will not be able to claim workers’ compensation benefits and you will be responsible for your own medical expenses and not be compensated for missed work and lost wages. Usually, to get an appeal on track you will need submit additional medical evidence that responds to the concerns of the employer and their insurer. You will need to provide details that dispel the concerns that caused your claim to be denied. You should consult with a workers’ compensation attorney who will be able to determine what is needed to get your claim on track and approved. The process of appealing a workers’ compensation claim denial can vary from one state to the next because states do set their own laws regarding workers’ compensation. In some states, you will be required to either meet with SAIF corporation before filing the formal appeal. The process could involve meeting with the employer or with the insurer, or it could involve both. While state laws vary regarding workers’ compensation and the claims process, the coverage and benefits that are provided are quite consistent. Workers’ compensation offers medical benefits, which cover the cost of the medical care you need to treat your injury, and it covers about two-thirds of your lost wages while you are recovering from the injury. In most states, your employer and their insurer can tell you which medical provider to see and they are contracted to form a network of providers ranging from general practitioners to specialists. However, if your injuries are serious, call an ambulance and go to the nearest emergency room. Be sure to maintain documentation to support your claim, such as copies of medical bills, medical records, and medical excuses. Be sure to document missed work and lost wages. Sometimes just meeting with your employer or their insurer could resolve the matter and have your claim approved. Some denials are simple clerical errors or misunderstandings. Sometimes a simple form may have been left out, or a question may not have been answered in detail. A workers’ compensation lawyer will know how to proceed with your claim and the best way to show that your injuries were work-related. If your claim cannot be resolved and your benefits reinstated or the claim approved, you will then file a formal complaint. Many appeals advance all the way to the hearing level. At that time, they will be reviewed by an administrative law judge. At the hearing level, your attorney will call witnesses, including anyone who saw the accident happen. Any video footage of the accident from surveillance cameras and other supporting evidence will be presented. The more evidence that can be gathered to support your claim, the more likely you will be to succeed with your appeal and to be given access to the benefits that you need during this difficult time after an accident while you were on the job. Always keep copies of all documents, so you will have them in case somehow they are lost or misdirected. Always keep duplicates of any evidence and documentation. What Happens At The Appeals Hearing? When your appeal reaches the appeals hearing, evidence will be presented. The hearing will proceed just like any other court case. You will need to provide hard medical evidence, witness statements, medical bills, medical records, proof of missed work and lost wages, and anything else that can help prove your claim and show that you were injured in a workplace accident. You will need to show that you are entitled to workers’ compensation benefits. You must be able to show that you were, in fact, injured while working. You will also need to prove that the injuries are permanent and are the direct result of the workplace injury. Your workers’ compensation attorney will know how to prove this and will ensure that your claim has a strong foundation. Workers’ compensation attorneys take cases on the contingency basis, so your lawyer will not be paid until you win your claim. Your lawyer will work diligently to ensure that your claim proceeds as it should and will also work to make sure you receive a settlement that is fair for your specific injury. Workers’ compensation claims do not cover the same damages as a personal injury claim, such as pain and suffering or mental anguish, so the settlement will not be as much as you would recover. Your lawyer will be familiar with the claims process, has strong negotiations skills, and will be able to gather supporting documentation and evidence to prove your case. If your claim advances to an administrative law hearing level, you will want to make sure you have legal representation. The hearing level is like any other court, so you will not want to try to represent yourself before the judge. Your lawyer will prepare you for questioning and will make sure you have everything in order so your claim can be properly reviewed, and everything will be available to be taken into consideration. If your workers’ compensation claim has been denied, you should enlist the help of a workers’ compensation attorney and get your appeal underway in a timely manner. Time is limited, and you don’t want to wait until is too late to appeal the decision. Tips to Guide You Through a Workers' Comp Claim Appeal Your workers’ compensation claim will be assessed by a state board dealing with these claims. If your claim is denied, you will be told why. This is important information for you to use to decide whether an appeal is possible and what you can do before an appeal hearing. Tip #1: Read the denial letter from SAIF's workers’ compensation board and make a note of the reason(s) for denial. Is the reason some kind of simple error on the part of your employer or someone at SAIF? Check with both to make sure that a mistake with dates, names or times hasn’t been made. Tip #2: If you think that your claim was justified and there was no time errors (claims can be denied if an injury or illness was not reported within a specified time frame, as is also the case with the claim itself) then it is best to contact a suitable attorney for legal advice. Tip #3: Based on advice from the attorney proceed with a request for an appeal against the decision on your claim. The appeal must be made within a specified time after receipt of the denial. Tip #4: You will be asked to attend an administrative hearing at some stage. At the hearing, a judge will consider all the evidence available that you have to support your original claim. This is the time that you can present new documentation to help your case for compensation. You may not have had the correct documents available the first time around. Listen to your attorney who will help you obtain anything which can be of use in supporting your claim. How a Reliable Workers' Comp Attorney Can Help You Appeal an Unreasonable WC Claim Denial Some claims are denied because of a simple mistake on the part of the employee, usually because of a lack of evidence or failing to keep to time limits. However, if your employer is being difficult or the insurer is objecting to the claim, you will need legal help to reverse a denial of your workers’ comp. claim. An experienced attorney will have dealt with many workers’ compensation appeals before and will be able to advise you whether an appeal is likely to succeed and how you can convince the judge at the appeal hearing that your claim was justified. *The content of this article serves only to provide information and should not be construed as legal advice. If you file a claim against SAIF Corporation, or any other company, you may not be entitled to any compensation.
