What to Do If Your Workers’ Comp Claim Gets Denied

Did you know that every year, both private and government employees file 4.9 million workers’ compensation claims? Approximately 67% of individuals who have their claims denied receive their compensation back through an appeal within a year. 

According to a workers compensation claim denial lawyer, a denied work injury claim could make a worker feel dejected, thinking that they are not deserving of medical and wage loss benefits. In contrast, a denial of claims only means that their injury is not work-related or that the claim for the benefits is otherwise invalid or fraudulent. 

Coming to terms with the reasons for the denial is important because there is a process that can be used to overcome it. Before you give up entirely, let us look at how to appropriately respond to the denial and build a stronger case.

Common Reasons for Workers’ Comp Claim Denials

When you file a worker’s compensation claim, it is necessary to understand if and why the claim can be denied. 

1. Lack of medical evidence. If you cannot prove that the injury did occur at the workplace, your claim may be dismissed. 

2. Missing deadlines. Each state sets certain time limits within which you must report your injury and file your claim. Do not miss those deadlines. 

3. Your employer may dispute the injury or claim that it occurred outside of work. That too may lead to denial. 

4. Inconsistencies surrounding the circumstances in which the incident occurred may raise suspicion. 

5. Another denial could be made if the claimant is intoxicated with alcohol or with drugs at the time of the accident. 

Having a good understanding of these will help you avoid potential stumbling blocks along the path of your claims.

Review Your Claim and Gather Documentation

Upon understanding the common reasons for workers’ comp claim denials, it is imperative to take a close look at the claim and its supporting documents. 

NC workers comp attorney Lyndon R. Helton says your lawyer can handle all aspects of your workers’ compensation claim for you including making an appeal. 

When reviewing your claim denial, look at any information that might have been missing or inconsistent and could have led to the denial. Such records include medical reports, accident reports, and witness statements. 

Look over these records for completeness and any up-to-date information provided. Keep a record of such communications with your employer or the insurer, as this could possibly make things clearer for you. 

Organizing your version of matters and filling any gaps will have you well equipped as you move on to present a better case for your workers’ comp claim.

Understand the Appeals Process

You will need to submit an appeal to review the decision. 

Make sure you read the claim denial letter in detail to understand the reasons the claim was denied. That is the basis of your appeal. Additionally, gather any other pertinent evidence in support of your case, such as medical reports or witness testimony. Pay close attention to particular deadlines; in other words, make sure your appeal is filed timely, as it varies from state to state. 

Then, you send your written appeal that lays down your reasons for setting aside the denial. Keep copies of everything you send. You will be assigned the date and place of a hearing after the appeal has been filed. The hearing is where your evidence will be presented. 

Seek Legal Assistance

If you are under the impression that you can handle your workers’ compensation appeal on your own, just remember that more often than not, legal counsel offers better odds in your favor. 

A workers’ compensation attorney would understand the nuances of the law and navigate around the system for you. They help prepare your documentation, put together a good case, and basically identify any holes in your claim. 

They would also discuss the matter with insurance companies on your behalf so that your rights do not get trampled. They would even prepare you for hearings, and if the case is brought to court, they will represent you there. If you allow them to put their experience to work, you can fully concentrate on your healing while they work to get you the benefits you deserve. 

Never underestimate the value of that advocate on your side.

Tips for Strengthening Your Claim for Resubmission

Having a lawyer on your side could easily turn around your case, but the resubmission also needs to be built on a strong foundation of your own. 

• Go through the denial letter completely so you know for sure why you were denied in the first place. 

• Prepare for the case by gathering every single file or document that may be related to the claim: medical records, witness statements, and probably the same kind of documents you had submitted in your initial claim. 

• Your evidence must have a strong argument relating the injury to the work duties. 

• When talking to an employer or the insurer, make sure to record everything so that you have a paper trail. 

• When an opinion is required, do not hesitate to get a second medical opinion for stronger support in your defense. 

Don’t waste time: start following up as soon as you can to keep the claim moving and demonstrate that you are taking the matter seriously.