When a claim is approved, you receive the money and benefits you need to recover and pay for day-to-day costs. So when a claim is denied it can feel like all your effort has been wasted. But you still have options! Depending on why your claim was initially denied, you can resubmit your claim and still be approved.
In fact, you may be in a better position than before according to a Lockton study. Lockton is an insurance business insider and the company found that nearly 70% of denied workers’ comp claims are later accepted with an average 55% higher settlement amount than the original.
Reasons your workers’ compensation claim was denied
1. Lack of medical records – Insufficient medical records is one of the top reasons claims get denied, especially in regards to pre-existing conditions. This is why it’s so important to see your treating physician right after the injury or incident occurred. Documentation can include physical exam results, consultation reports, copies of lab or x-ray tests, or hospitalization reports. These records play a major role in determining the amount of treatment and compensation required. And if you filed a claim based on an aggravated existing condition you will need to provide documentation about the nature of your condition, any treatments you’ve undertaken, and when exactly it got worse.
2. Missed deadlines – You need to formally file a claim by the state’s deadline in order to qualify for benefits. In California, that means submitting your DWC 1 form within one year from the date of your job-related injury or illness. Ideally, however, you should report the incident as soon as possible. Keep in mind that under California law, chronic stress and other mental health problems that are sustained due to your work environment are also eligible for workers’ comp.
3. Not a work-related injury – Your employer may claim that you were off duty during the time of the injury, or that your current illness is the consequence of a pre-existing condition and not actually work-related. This is a tricky situation and especially complicated for injuries or illnesses sustained while working from home.
4. You’re no longer an employee – Being fired in retaliation for reporting a workplace injury is illegal. But you might have left voluntarily, either because of a better opportunity or because you happened to be injured after giving notice but before your last official work day. Insurers tend to deny claims filed after a claimant is no longer part of the company because the employer is only obligated to provide workers’ compensation for people that work directly (though sometimes even indirectly) for the company. As long as your injury or illness occurred while you were still employed, however, you are entitled to benefits even if you decide to leave.
5. No witnesses – A workplace injury with zero witnesses is suspicious. It becomes even more suspicious if you wait before reporting the incident. This is why it is so important to tell people as soon as the injury occurs, write down exactly what happened, and speak to anyone that was nearby when you were injured. If your accident occurred without any witnesses or security footage available, you need to make sure that your story is consistent every time you tell it.
6. Discrepancies in your report – All evidence provided is thoroughly reviewed before the insurance company comes to a decision. If the report you filed, your medical record, and witness statements don’t match, the claim is likely to be denied. Try to keep a record of what happened right from the start because, as time goes by, you are likely to forget certain details which can hinder the credibility of your report.
7. You were to blame – Obviously, if you obtained an injury as the aggressor in a fight, or while committing a crime, violating company policy, drunk or high you may not be eligible for workers’ compensation. Employers might also use a pre-existing condition as an excuse to deny you coverage. But your employer is still required to pay for any pre-existing conditions that were aggravated by the nature of your job or job-related accident (think hearing loss, PTSD, and muscle strain). In California, this extends to chiropractic needs, physical therapy, and occupational therapy as well.
Your decision letter should include reasons why your claim was denied. If it was a matter of missing paperwork or miscommunication, you might be able to contact the claims adjuster yourself and resolve the issue. Unfortunately, anything beyond a clerical error or missed deadline will likely require an appeal.
Appealing a claims denial
Appeals regulations and processes vary by state. In California, you have 20 days to file for appeal after receiving a decision letter from the insurance company. In order to file for appeal you will need to submit an Application for Adjudication of Claims form.
The first level of appeal will be a hearing in front of a California Workers’ Compensation Appeals Board (WCAB) judge. The judge will hear arguments by you and the insurance company. You will want to bring as much documentation and evidence as you can to this hearing, including medical records or timesheets proving you were officially working during the time of the injury. The WCAB judge will either approve the workers’ comp claim or side with the insurance company, in which case, your appeal might have to go up to a Circuit Court or (in extreme instances) a Superior Court.
Getting help
The appeals process is complicated in every state. Judges will expect you to be familiar with civil procedures and rules of evidence. Mistakes at this stage could prevent you from furthering your case. If you are unsure of how to proceed with a workers’ comp claim, or confused about what’s required in an appeals process, don’t hesitate to contact a lawyer. An experienced workers’ compensation attorney will not only be able to explain which benefits you qualify for, they will fight to ensure you receive them.
Barsoum Law is here to support you and protect your interests throughout the entire workers’ comp process. We offer a personal focus and individualized care that large corporate firms do not. And our multilingual, multicultural team is dedicated to making sure you obtain the compensation you deserve.
If you have suffered a work-related injury or illness, Barsoum Law can and will help. We have represented thousands of injured workers throughout California the past 25 years. Contact us today at 877-299-1555 or info@barsoumlaw.com to schedule a consultation with a member of our team.
Summary
When a claim is approved, you receive the money and benefits you need to recover and pay for day-to-day costs. So when a claim is denied it can feel like all your effort has been wasted. But you still have options! Depending on why your claim was initially denied, you can resubmit your claim and still be approved.
Reasons for denial include missing deadlines, dispute over whether the injury was work-related, discrepancies in your report, a lack of witnesses, or that you no longer work for the company. If it was a matter of missing paperwork or miscommunication, you might be able to contact the claims adjuster yourself and resolve the issue. Unfortunately, anything beyond a clerical error or missed deadline will likely require an appeal.
The appeals process is complicated and varies by state. Judges will expect you to be familiar with civil procedures and rules of evidence. Mistakes at this stage could prevent you from furthering your case. If you are unsure of how to proceed with a workers’ comp claim, or confused about what’s required in an appeals process, don’t hesitate to contact a lawyer.
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