When a covered employee is injured on the job or within the scope of their employment, workers’ compensation kicks in to cover lost wages, medical bills and rehabilitation costs. Often, however, disputes arise over whether the injury is covered. When such a dispute occurs, the workers’ compensation insurance provider may deny a claim.
Claims can be denied for some of the following reasons:
If your claim has been denied, an experienced attorney can help you go through the process of filing a claim to get the compensation you deserve.
If your denial is for something other than missing paperwork or incomplete claim files, ask if they will reconsider their decision. Sometimes a simple second review or reconsideration will cause the provider to approve a claim.
The first step is to file the proper paperwork with the correct administrative agency. Most states have an administrative board that oversees workers’ compensation claims and appeals. In Georgia, this agency is the State Board of Workers’ Compensation. Once you file your claim, the agency will schedule a hearing.
Administrative hearings are much like court hearings. Administrative agencies act in a quasi-judicial capacity. Administrative law judges oversee the hearings, where both sides appear and provide evidence of their respective cases. Like a court hearing, specific rules and procedures must be followed. Failing to follow these rules and procedures can result in negative outcomes.
Once the hearing is completed, the administrative agency will make a ruling on your case. If your denial is found to be improperly denied, then your provider will be forced to accept your claim. If the administrative law judge finds that the denial was proper, then the provider doesn’t have to pay your claim.
Once the Board of Appeals has issued a ruling, this typically fulfills the “exhausting of remedies” requirement needed to appeal your case to a court of law. Usually, before any court of law hears an appeal from an administrative law agency, a person must exhaust all available administrative remedies. Once this is done, your case can enter a court of law.
Some of the claims process can be done alone, but once you get into a hearing, court and appeals, it is always better to have an experienced professional on your side. Having a lawyer can increase your chances of winning your workers’ comp case.
Many claims are denied due to medical reasons. A lawyer who has been through the process before can help guide you to the correct medical professional. They will also help contact witnesses and fill out the proper paperwork.
As noted above, the process is full of rules and procedures that will take you hours or research and reading to learn. An experienced lawyer knows this process already, and they can focus more on the facts of your case. Though having a lawyer may seem expensive, most workers’ comp lawyers work on a contingency fee. This means they take a small percentage of any claim you may be paid.
Once again, Westmoreland Law has been recognized by its peers as part of an elite group of approximately 10 percent of all attorneys who hold an AV Preeminent Rating. An AV Preeminent Rating is a designation trusted worldwide by buyers and referrers of legal services.
