Workers’ Compensation Claim Denied? Follow These Steps.

Was your workers’ compensation claim denied? Your related expenses should be covered by your employer’s workers’ compensation insurance; however, sometimes these claims are not approved. If your claim was denied, don’t fret. The attorneys at Ellis & Associates can help you understand why your claim failed and walk you through the steps to recover benefits for your losses.

Why Is a Workers’ Compensation Claim Denied?

Why was your workers’ compensation claim denied? To understand, start by reading your denial letter carefully. The insurance company should list the reasons it denied your claim. For example, you may have waited too long to notify your employer or failed to receive medical treatment. All of the following reasons may cause an insurance company to deny your claim:

• Your employer disputed your claim by arguing that it did not happen at your job, resulted from horseplay, or because of another disqualifying reason.
• You did not report your injury to your employer soon enough. In Massachusetts, employees must report injuries to their employers as soon as possible.
• You did not file your claim on time. In Massachusetts, you must file your claim within four years of when you were injured.
• You did not receive medical treatment.
• Compensation is not available for your type of injury.
• You did not submit enough evidence to show that your injury happened at work.

An attorney can help you figure out whether the reasons cited are valid. If they are not, you may consider appealing the denial of your claim.

Filing an Appeal of the Denial Decision

Before you file an appeal, you should talk to your employer or the insurance company to figure out whether you can easily resolve the dispute. The denial may have happened because of a simple misunderstanding or a clerical mistake.

If you are unable to resolve the dispute, you can file an appeal with the Department of Industrial Accidents.  You will need to complete the claim form, which will ask for the following information:

• When you were injured
• The body parts that were affected
• The first and fifth dates on which you missed work
• The name of the insurance company
• The types of workers’ compensation benefits you are seeking
• The name of your treating physician
• How long you anticipate being off from work
• The date you first sought treatment

In your denial letter, you should be given a deadline for appealing the decision. Make sure to pay attention to this deadline because if you wait too long to file an appeal, your appeal may be denied.

Conciliation

The DIA will schedule a conciliation, which is the first step in the appeals process. This is an alternative dispute resolution process that will be attended by you, your attorney, the insurance company’s attorney, and a conciliator. You will want to bring any documentation of your injuries, your treatment, information about what happened, the time that you missed from work, and other evidence.

If an agreement is reached during the conciliation phase, your appeal will be over. The agreement will be adopted by the DIA as its order to resolve your claim. If your claim is not resolved, it will be scheduled for a conference.

Conference

The conference is an informal meeting that is attended by you, your attorney, the insurance company’s attorney, and an administrative law judge. If your dispute is resolved during the conference, the administrative law judge will issue an order for the insurance company to begin paying benefits to you. If you do not agree with the outcome of the conference, you must file an appeal within 14 days. The insurance company can also appeal the judge’s order.

Hearing

If the conference order is appealed by you or the insurance company, a trial will be scheduled. At this hearing, you can call witnesses. A stenographer will be present to document the proceedings. You can submit evidence, and the administrative law judge may request oral testimony. Once the administrative law judge issues a decision, you will have 30 days to file an appeal with the Department of Industrial Accidents Reviewing Board.

Reviewing Board Phase

If your case is appealed to the Reviewing Board, the board will review the transcripts from your hearing. Your lawyer and the insurance company’s attorney will file legal briefs. The Reviewing Board may ask for oral arguments. It can affirm the administrative law judge’s decision or send it back for additional findings.

Contact Ellis & Associates for Help

The appeals process for workers’ compensation claims can be complicated. However, denials can be appealed successfully. Working with an experienced attorney at Ellis & Associates might improve your chances of succeeding with your appeal. To schedule your free consultation, call 800-MR-ELLIS or send us a message online.