What to Do If Your Workers' Comp Claim Is Denied

Receiving a letter that your workers’ compensation claim has been denied can be a frustrating and confusing experience. It might feel like the end of the road, but it's important to understand that a denial is not a final decision. Many initial rejections can be successfully overturned. In fact, on average, a significant number of denied workers' compensation claims ultimately become paid claims.

So, why was your claim denied, and what can you do next?

Understanding Why Your Claim Was Denied

A workers’ compensation claim is denied when the claims administrator believes your injury is not covered by the insurance policy. This doesn’t mean the fight is over; it simply means you need to challenge their decision. When you receive a denial letter, you have the right to appeal. Do not delay, as there are strict deadlines for filing the necessary paperwork.

Here are some of the common reasons a workers' compensation claim may be denied:

• Late Filing: There are specific time limits for reporting an injury to your employer and for filing a claim. Missing these deadlines is a common reason for denial.

• Insufficient Medical Data: The claims administrator may feel there isn’t enough medical evidence to prove your injury is work-related or severe enough to require compensation.

• Injury Sustained Off the Clock: Workers’ compensation typically only covers injuries that happen while you are performing your job duties. If the injury occurred during a non-work activity, your claim will likely be denied.

• Employer Dispute: Your employer might dispute that the injury happened at work or that it was caused by your job.

• Damage Doesn’t Fit Long-Term Injury Definition: Some claims are denied because the injury is not deemed serious enough to warrant long-term benefits.

• Errors in Paperwork: Simple mistakes or omissions on your claim forms can lead to an immediate denial.

While a denial can be disheartening, remember that it is often a procedural step rather than a final judgment on your injury. Many compensable situations are initially rejected, and persistence is key.

Disagreements About Benefits and Medical Evaluations

During the claims process, it's common for disagreements to arise between you, your doctor, and the claims administrator regarding the nature of your injury, the required treatment, or the extent of your benefits. When such a dispute occurs, you may need to undergo an evaluation by an independent medical professional.

This is where a Qualified Medical Evaluator (QME) comes in. A QME is a physician who has met additional educational and licensing requirements, passed a specific test, and participates in ongoing education about the workers' compensation evaluation process. If you are unrepresented, the Division of Workers' Compensation will provide you with a list of QME's to choose from. You and the claims administrator can then submit information to the QME, who will examine you and issue a report that can help resolve the medical dispute.

If you have an attorney, you and the claims administrator may agree on a specific doctor to resolve these medical disputes. This doctor is called an Agreed Medical Evaluator (AME). The report from an AME is often highly influential in the outcome of your claim.

Your Options After a Claim Is Denied

When your workers' compensation claim is denied, you have a few distinct paths you can take to move forward. Your choice will depend on your personal circumstances and how determined you are to pursue the benefits you believe you are owed.

Accepting the Denial (Personal Decision):

After receiving a denial, an injured worker may decide to accept the insurance company’s decision at face value and stop pursuing their claim. This is a personal choice, but it will result in the claim being closed. While this may seem like the simplest route, it means you forfeit any potential medical care and financial benefits.

Independent Physician’s Review (QME Process):

If you decide to dispute the denial, you can choose to go through the Qualified Medical Evaluator (QME) process. This involves formally objecting to the insurance company's decision and requesting a panel of independent physicians to choose from. After selecting a QME, you will have a separate physical examination with them. Both you and the claims administrator will present your information to the QME. The QME's report could potentially overturn the initial denial. If the denial is overturned, the claim will remain open for medical care until you are medically discharged, the case is settled, or a judge from the Workers' Compensation Appeals Board (WCAB) issues a decision.

Obtaining Legal Representation:

A third and often most effective option is to hire an attorney. An experienced workers' compensation attorney can guide you through the complex legal process. They can help you with:

• Adding Body Parts: If your injury has affected other parts of your body, an attorney can help ensure these are included in your claim.

• Pursuing Additional QMEs: They can arrange for additional QME's for various body parts as needed.

• Setting Hearings: Attorneys are skilled at navigating the legal system and can set hearings to move your case forward.

• Driving a Resolution: While some may believe attorneys simply drag out the process, their primary goal is to ensure you receive a fair and just resolution, whether through a settlement or a judge's order. Claims are not completed until they are dismissed, settled, or a judge issues an order called a "Findings and Award."

First Steps to Take After a Claim Is Denied

No matter which option you choose, the very first step you should take after a claim denial is to gather all your documents. This includes:

• The denial letter itself.

• All medical records and reports related to your injury.

• Any communication you have had with your employer or the claims administrator.

• Your initial claim form.

• Any other paperwork related to your injury and employment.

Having all your documents organized and ready will be crucial for the next steps, whether you decide to pursue the claim on your own or with legal help. By taking swift and informed action, you can significantly increase your chances of overturning the denial and securing the benefits you deserve.

The reality is that accidents can occur unexpectedly, despite taking all necessary safety measures. If you have queries or issues about a work-related injury, hazardous work environment, or unjust treatment, don't hesitate to contact us for a complimentary consultation and case evaluation.

To learn more or share your experiences call Barsoum Law (877) 299-1555 or schedule a consultation online.

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