Sometimes when an Employee is legitimately injured on the job, the claim may be denied by the Claims Administrator and/or Human Resource Department. Even though the process may be frustrating and lengthy, it helps to understand the reasons why a claim may be denied. The following explanation will help you navigate the compensation process with greater precision.
Reasons You May be Denied
1) One of the primary reasons for denial is the lack of credibility that the claim was indeed related to a work injury.
2) Failing to report the injury to the Employer on a timely basis can be problematic. This is often the most common reason for a workers’ compensation claim being denied. The Employee simply waits too long. Several states feature a “statute of limitations” and if the time runs out; then the claim can be denied.
3) Another reason maybe be the injured Employee had no witnesses to vouch for him or her at the time of the incident.
4) Another common reason is when an Employee is injured and does not file the claim for fear of being terminated from his or her position. There are some instances where a claim can be denied because of illicit drugs and/or alcohol being found in the Employee’s system. This will often cause the claim to be denied on the basis that the Employer can and often assumes that the injury was caused because the Employee was intoxicated and was not adhering to any and all safety rules, precautions, etc.
Disputing the Workers Compensation Denial
The Employee does have a right to dispute the decision. However, there is a time restraint as to when and how to dispute this decision.
The first step is to hire a workers’ compensation attorney to review the injuries, medical bills, circumstances surrounding the incident and then determine the following recourse to get the denial overturned. In most cases, an Employee will have the case taken to Court and heard before a Workers’ Compensation Administrative Law Judge.
In most cases, the insurance company which covers the Employer will hire their own attorney to represent both the Employer and the insurance company’s interest. Often, if a claim is deemed to be truthful a settlement can be reached via a Mediation between all parties and then there is no need for the use of the Judge. However, this can become frustrating and a long process.
The Discovery Process
The discovery process involves the taking of depositions. Testimony by several parties must be provided, including both attorneys. All parties will exchange information about the incident, medical records, background information of the Employee, etc. Requests for the production of certain documents, including but not limited to medical records, interrogations, admissions, statements and/or depositions, examinations under oath, are requested from the Employee and from attending doctors treating the Employee to determine if any of the injures can be attributed to any past ailments or if indeed the injuries sustained are all related to the incident being claimed.
After the discovery portion, a Mediation between the parties will take place before a Mediator assigned by the Court. This Mediator is an impartial person and will investigate all the documentation provided by both parties and the testimony from all parties.
A meeting is set and a settlement offer is presented to the Employee by the part of the Employer and its insurance company. Often, the settlement offer includes payment of any past, current and future medical bills associated with the injury, payment to the Employee’s attorney for his time and effort in the case, loss of time from work for any medical appointments and some extra monies are always involved so that the Employee can be compensated for the injury and to ensure that no future claims will arise from this claim.
The Employee is granted the opportunity to continue working without prejudice of any kind from the Employer and if contingent employment cannot be offered, a specific amount to cover severance is offered to allow the Employee ample time to seek employment elsewhere.
If the Employee and his or her attorney determine that the settlement amount is not enough to cover all these expenses then the settlement is rejected resulting in an impasse on the Mediation. Sometimes a second Mediation is offered. If there is no median or settlement reached, then the case is often taken to Court and the determination of the Judge and his or her ruling will become final.
This can be a 50/50 situation for the Employee and for the Employer, the Judge takes into consideration the Mediations’ outcomes and looks over all the evidence. The Judge’s ruling can be lower or higher than what was offered at the time of the Mediation and the verdict is final. Sometimes it works out in the favor of the Employee and sometimes it works out in the favor of the Employer. Overall, it is a tedious process and the outcomes are never the same. Always remember: each case can be vastly different.
If you or someone that you know has been injured on the job, that injured person is entitled under Georgia law to file a workers compensation claim. In many cases, the victim may be eligible to receive Georgia workers’ compensation benefits, including wage benefits as well as medical benefits. Speak with one of our compensation lawyers in Savannah, Atlanta, or Madison, to discuss the merits of your claim.