When Workers’ Compensation Claims Are Wrongly Denied

When workers are injured on the job, they are often eligible for workers’ compensation, which pays for the injured worker’s medical expenses, treatments, and a portion of the worker’s wages. But there are many legitimate reasons why a workers’ compensation claim might be denied. The worker might not be a covered class of worker that is eligible for workers’ compensation; the worker might have been reckless or willfully responsible for his or her own injuries; or the worker might be negligently responsible for causing his or her own work-related injuries.

On the other hand, there are many injured workers who have workers’ compensation claims that get denied for no good or legitimate reason. Sometimes a workers’ compensation claim is accidentally denied – claim processors might be overworked or overloaded with claims and they simply deny a claim to save on time, or the workers’ compensation claim processor might not be trained well enough to know that a claim should be allowed.

Whatever the case may be, if you are an injured worker who needs workers’ compensation benefits for your work-related injury and you believe that your workers’ compensation claim was wrongly denied, you need to speak with an experienced workers’ compensation lawyer as soon as possible about your denied claim. An Atlanta workers’ compensation lawyer can help you appeal a denied workers’ compensation claim so you can get the workers’ compensation benefits you are entitled to.

Reasons Why Workers’ Compensation Claims Are Denied

In addition to certain acts that can make a worker ineligible for workers’ compensation benefits, there are other reasons why a workers’ compensation claim will be wrongly denied. Some common reasons why workers’ compensation claims are denied include, but are not limited to:

  • Processor’s mistake. It is possible that the workers’ compensation claim processor made a mistake when processing your claim. The processor could have been working too quickly, or could have been inadequately trained. When a workers’ compensation claim is denied by mistake, it is usually fairly easy to show that there was an error.

 

  • Questions about reporting deadlines. When a worker is injured on the job, the worker has a duty to report his or her injury to their supervisor, boss or employer within 30 days of suffering the injury. This report must include the injured worker’s request for medical treatment. This is considered notice to your employer and it is required for every workers’ compensation claim. If there is any question regarding whether you, as the injured worker, gave proper and timely notification of your injury to your employer, then there is a possibility that your workers’ compensation claim will be denied. An experienced workers’ compensation lawyer can help you demonstrate that you reported the accident and your injuries as required, and that you workers’ compensation claim should not be denied for not notifying your employer.

 

  • Questions about filing deadlines. Injured workers have one year from the date of their injury to file a workers’ compensation claim. This is in addition to reporting the work-related injury to your employer within 30 days of suffering your injury. Claims that are not filed within one year of suffering the injury are considered time barred and will not be actionable. If there is a question about whether or not your workers’ compensation claim was filed within the one year deadline for filing, the claim processor may deny your claim.

 

  • Questions as to whether the worker actually needs medical treatment. A workers’ compensation processor or employer might deem the worker’s reported injury as not requiring medical care. But if you believe that your injuries do require care, then your claim should not be unduly denied.

 

When Employers Discourage Workers From Using Workers’ Compensation

Some employers try to dodge their responsibility to provide workers with workers’ compensation benefits, and will try anything to discourage a worker from filing a claim. The employer might tell a worker that they are not entitled to workers’ compensation for their injury, or that you must seek medical care on your own. This is not true.

Nearly all employers are required to have workers’ compensation insurance for nearly all types of employees. This means that practically all employees in Georgia are eligible for workers’ compensation benefits. Your employer cannot tell you  to seek medical care for your work-related injury through your own health insurance or that you must pay for medical treatment for work-related injuries out of pocket. If you are covered by workers’ compensation, your employer also cannot or require you to take sick leave in order to recover instead of seeing a doctor.

Employers also might try and avoid paying for the injured worker’s medical care by not following up with the injured worker. The employer might send the injured worker to a doctor initially, but when that doctor recommends additional treatment with specialists, the employer might unnecessarily drag its feet to coordinate the prescribed treatment for the injured worker. During this time, the injured worker is helpless since he or she cannot seek out medical care on their own. They might feel like they are at the mercy of their employer and their employer’s workers’ compensation coordinator. When your employer wrongly denies your workers’ compensation claim, or unduly delays your treatment in Atlanta, you need to consult with an experienced workers’ compensation lawyer as soon as possible.

Find Out Why Your Claim Was Denied

The first thing you need to do if your claim was denied is to find out why. The Georgia State Board of Workers’ Compensation oversees workers’ compensation claims. You will receive a letter that should provide you with information regarding the status of your claim. If the board denied the claim, it will give you the reason the claim was not approved. There are numerous reasons why it could deny a claim. The claim may not include complete details or the board could believe that the injury did not occur at work. That is why it is critical to report the injury to your employer immediately when it occurs. Regardless of the reason for denial, you have the right to appeal the decision.

5 Reasons an Insurer Could Deny a Workers’ Compensation Claim

Unfortunately, claims are denied by insurers all the time, often unjustly. In some cases, it might be because human resources departments and the employers’ insurance claims adjusters were poorly trained or carrying too heavy a workload to assess the claims properly. In other cases, the insurer may use whatever excuses it can in order to reject the claim to reduce payouts. Insurers are, after all, for-profit businesses, and their bottom-lines tend to supersede workers’ needs.
There are several legitimate reasons an insurer might deny a workers’ compensation claim. Below we briefly discuss five of the most common reasons claims get denied. However, no matter the insurer’s reason for denying your claim, you should consider hiring a workers’ compensation lawyer to request a hearing and defend your rights to income benefits. 

1. Statute of Limitations 

There is a time limit, or statute of limitations, on when you can file a workers’ comp claim. The State of Georgia provides different statutes of limitation depending on the particular circumstances. The time limits range from one year to four. You should ask your attorney which applies to your situation.

2. Type of Employment 

There are certain types of workers who are not eligible for workers’ compensation benefits. These workers are:

  • Farm laborers.
  • Federal government employees.
  • Independent contractors.

If a workers’ compensation insurer denies your claim on the basis of your employment status or employment type, there might still be a way to prove your eligibility. Learn more here.

3. Intoxication

If your employer uses intoxication and drug test results as the basis for denying your workers’ compensation claim, you can and should request a hearing. Click to read more on denials based on intoxication and drug tests.

4. Causation

Insurers deny some claims because they argue that the worker’s injury or illness is not work-related. In order to qualify for workers’ compensation benefits, it has to be proven that your injury was caused by a work accident or work-related duties. Read our full page on causation to learn more.

5. Undisclosed Pre-Existing Injury

Employers may try to deny your claim by accusing you of hiding a pre-existing injury or condition that contributed to or exacerbated your current injury. If the denial is based on this assumption, the employer and insurer will have to prove it. Learn how by reading our full page on pre-existing conditions.

How to File a Workers’ Compensation Appeal

If you feel your claim should have been approved, you can file an appeal. You have a limited time to appeal, so you must act quickly. Generally, you have 20 days from the date of the denial to file an appeal. You must appeal through the appellate division and must do so in accordance with the rules. It is helpful to seek legal help from a knowledgeable workers’ compensation attorney. Your lawyer knows how to resolve these types of cases most favorably.
Do not delay, because if you miss the deadline to appeal, you will not have any recourse in the situation. If you don’t think the appeal results were adequate, you can take your appeal further. It is best to file an appeal with help from an experienced workers’ compensation attorney. Your lawyer knows what information to provide in order to ensure a strong case. Your lawyer will assist you in getting the benefits that you deserve.

What to Do If Your Claim Is Denied

Sometimes a workers’ compensation claim is denied and when that happens you need to take action. If the claim was denied you should receive a notice, however, your first indication may be that you are not receiving payments for your workers’ compensation benefits. The claim may have been denied by your employer or by the State of Georgia State Board of Workers’ Compensation (SBWC).   
You may request a hearing in front of the SBWC. You may represent yourself at the hearing but it is strongly recommended that you seek legal representation from an experienced Atlanta workers’ compensation attorney. Your attorney has the expertise to handle these types of hearings and will gather all of the documentation and details necessary to present to the board. Once you complete and file a request for a hearing you will be assigned a judge and hearing date.

What to Expect at the Hearing

The hearing is a place where you or your attorney will have the opportunity to present your evidence and proof that your employer owes you workers’ compensation benefits. In some cases, you may need to meet with a mediator first before the hearing date. A mediator is a professional who assists in facilitating resolutions between two parties. You and your attorney will meet with your employer or insurance company representative and the mediator to discuss your on-the-job injury.
If you can’t reach an agreement during mediation, the matter will go to the hearing. The hearing is your chance to present all of your evidence including witnesses. Keep in mind that you generally must present witnesses in person rather than provide witnesses’ statements alone. For example, you may want your doctor to testify about your injuries. Your physician will also be able to provide medical records and other items documenting your injury. Your employer may also bring witnesses to testify that the injury didn’t occur the way you stated or that the injury didn’t happen at work.

Workers’ Compensation Lawyers Ready to Help You

All too often in Georgia, honest workers who are injured on the job are denied workers’ compensation benefits for one reason or another. However, these injured workers often have a legitimate claim and they are genuinely in need of medical treatment for their work-related injuries. Having your workers’ compensation claim denied can be devastating and can leave you not knowing what to do. But do not worry – you should reach out to an experienced Atlanta workers’ compensation attorney about your situation as soon as you can. The professionals at Bader Scott Injury Lawyers can assist you with every aspect of your workers’ compensation claim. Contact us today.

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