What To Do If Your Workers’ Compensation Claim is Denied

Sometimes when an employee is legitimately injured on the job, the claim may still be turned down by the company’s claims administrator and/or Human Resources Department. The workers’ compensation process can be complicated, frustrating, and lengthy, so it helps to understand the reasons why a claim may be denied.

3 Reasons Your Worker’s Comp Claim May be Rejected

1) One of the primary reasons for denial is a lack of credibility that the claim was indeed a work-related injury. For instance, the injured employee had no witnesses to vouch for him or her about the incident.

2) Failing to report the injury to your employer on a timely basis also a common reason for a refusing a workers’ compensation claim. Sometimes the employee simply waits too long. Several states feature a “statute of limitations” on filing and if the clock runs out your claim can be denied.

3) The employee is injured but does not file the claim for fear of termination from his or her position. In some instances a claim can be denied because of an employee’s illicit drug and/or alcohol use. If this is the case the employer can (and often does) assume the employee was intoxicated and not adhering to any and all safety rules, precautions, etc.

Disputing a Workers’ Compensation Ruling

As an employee you do have a right to dispute a negative decision, however there is also a time constraint regarding when and how to dispute a ruling.

The first step is to hire a workers’ compensation attorney to review the injuries, medical bills, and circumstances surrounding the incident, then determine the next course of action. In some cases an employee will decide to take the case directly to court before a workers’ compensation administrative law judge, prompting the employer’s insurance company to hire an attorney to represent both the employer and the insurance company’s interest. Oftentimes, though, mediation (see below) can bring about a settlement agreeable to all parties and there is no need to go before a judge.

The Discovery Process

The discovery process involves taking depositions. All parties involved, including both attorneys, provide testimony and exchange information about the incident, the employee’s background information, etc. The employee and any attending doctors must fulfill all document requests, including but not limited to medical records, interrogations, admissions, statements and/or depositions, and examinations under oath to determine if any of the injures claimed can be attributed to past ailments or if indeed they are all related to the incident in question.

Mediation

After the discovery portion is complete an impartial, court-appointed mediator will review all of the documentation provided by both parties and schedule a meeting where the employer will offer a settlement to the employee. The settlement offer will often cover payment of any past, current, and future medical bills associated with the injury, the employee’s attorney fees, and compensation for lost work time due to medical appointments. Also, extra compensation is added to ensure that no future claims associated with the incident will arise. The employee is also granted the opportunity to continue working without prejudice of any kind from the employer or, if contingent employment cannot be offered, a severance package may be provided to allow the employee ample time to seek employment elsewhere.

If the employee and his or her attorney determine that the settlement offer is unsatisfactory, it is rejected, resulting in an impasse. A second mediation session may be offered, but if no settlement is ultimately reached through mediation, a judge will then make the final ruling.

This can be a 50/50 situation for both the employee and for the employer, as the judge will consider all the evidence, plus the mediation offer. The judge’s ruling may be lower or higher but the verdict is final.