Dealing With Workers’ Comp Denial
I’m Ed Smith, a workers’ compensation lawyer in Sacramento. Being injured at work is stressful enough. Filing a claim with a myriad of deadlines and complexities adds a whole new layer to that stress. Later, if a claim is denied, a worker suddenly has to worry how he or she will pay the bills on top of everything else. Workers’ compensation denial is based on many things. Let’s take a look at why a denial happens.
Reporting a Denial
The insurance company must tell a worker that their claim has been denied within 21 days. If the insurer fails to do that, the insurer could be charged penalties, interest and lawyer fees. After the worker receives a denial, it is possible to challenge it, depending on the reason it was denied.
Reasons for Denying a Workers’ Compensation Claim
Some common reasons for benefit denial under workers’ comp are:
- The claim was not filed in time. This is one of the most common reasons. When a worker is hurt, they should report the work-related injury as quickly as possible. In California, you have up to 30 days to report the injury. Waiting more than a few days is not a good idea. It could be construed that the injury was not very serious.
- Important details were omitted. Often the claim will be denied until the details are provided.
- The accident was not reported.
- Paperwork was not complete: This is a frequent problem and one which can end in denial.
- No witnesses were provided. While some injuries are unwitnessed, insurers may question unwitnessed accidents. That does not mean that they will not approve benefits eventually, but they may ask questions about it or deny it at first.
- Medical treatment was not sought. When a worker fails to seek medical treatment or the treatment was meager compared to the reported injury, the claim may be questioned or denied.
- The claim was filed after the worker left the employ of the company: This is another reason not to delay filing a claim.
Preexisting Conditions Can Complicate Claims
If there is a relationship between the injury and a pre-existing condition, a claim may be denied. There are times when an injury is compounded by a pre-existing condition. For example, a worker hurts his back but may have been treated for a back injury years earlier. Depending on the type of work, it is feasible that a worker could injure themselves in a body area that was previously hurt. In this case, medical documentation is needed to differentiate one injury from another.
Discrepancies in Reporting the Accident
If discrepancies as to how the accident happened exist, the claim may be rejected.This happens when a worker tells his or her employer about the accident and then tells medical caregivers or others a different accounting. It is important to be consistent in recounting the details of the accident. It is also important to make sure that whomever you are recounting the accident to understands the details clearly.
Medical Authorization
A medical compensation insurer will ask for medical authorization to review the employee’s medical treatment. If the employee fails to give medical authorization, the claim may be denied. However, there are many variables present in such a request, and it depends on the type of authorization that is being sought. If the insurer is asking for permission to receive all of an employee’s medical records, they may be trying to look for preexisting conditions that could lead to claim denial. It you have retained a workers’ compensation lawyer, it is best to allow the attorney to respond to such requests.
What to Do After a Denial
A denial can be appealed. Instructions as to how this can be done are usually provided along with the denial letter. On occasion, if the denial was due to a lack of information, by providing the information, the denial may be reversed. There is also a time limit to filing an appeal. You have 20 days from the time you received the decision if the decision was given to you in person. However, if you received a response to your claim in the mail, you have 25 days from the time of the decision to ask for reconsideration.This holds true even if the denial is for specific portions of the claim. For instance, benefits may be awarded, but specific parts of the claim such as surgery may be denied. It is important to include documentation and new evidence and to be detailed as to why you think the denial was in error. The board has 60 days to respond.
Appeal to a State Appellate Court
If the appeal does not reverse the original decision, another appeal to a state appellate court is possible. You have 45 days to file this request for a review. Since this review has limited power, asking a workers’ comp lawyer about it is advisable.
The Advice of a Workers’ Compensation Lawyer
The advice of a workers’ compensation lawyer is invaluable in workers’ compensation cases. Whether the worker is filing the claim or challenging a denial, an experienced attorney can make sure deadlines are met and appropriate documentation is provided. It is essential to have both an initial claim and subsequent appeals meet the requirements for a favorable outcome.
Related Articles by Sacramento Workers’ Compensation Lawyer, Ed Smith:
- What Are Employer Responsibilities in Workers’ Comp Cases?
- Medical Benefits for an Injured Worker
- Frequently Asked Questions About Workers’ Compensation
Sacramento Workers’ Compensation Lawyer
I am Ed Smith, a workers’ compensation lawyer in Sacramento. If you’ve been denied workers’ compensation, you have the right to appeal that decision. You will benefits from the advice of an attorney experienced in such matters. Call me at (916) 921-6400 or (800) 404-5400 for both free and friendly advice. You can also reach me online too.
I have assisted residents of Sacramento and Northern California in my capacity as an injury lawyer with workers’ comp cases, wrongful death and other traumatic accidents for more than 35 years.
Would you like to read former client’s comments and reviews of my law practice? Go to Avvo, Yelp and Google.
My past verdicts and settlements are available to you.
I established and own AutoAccident.com. It is intended as a place for clients to read about personal injury law.
I’ve won awards and settlements for clients of $1 million or more. Because of this, I was inducted into the Million Dollar Advocates Forum.
Photo Attribution: https://pixabay.com/en/construction-worker-safety-2578410/
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