Steps to take when filing a workers’ comp claim, and when to consult an attorney
Most often referred to in short as “workers’ comp,” workers’ compensation is an insurance system put in place to help employees who are injured on the job. State law dictates what employers must cover their employees.
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:
- The injury did not occur at work
- A preexisting injury
- Medical provider notes the injury will not affect their ability to work
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.
What to do with denied claims
Here are the steps for dealing with a denied claim.
1. Documentation
One of the best first steps to take is to gather all of your documentation and create a log of events. Get a file and place all doctor bills, letters or emails from your employer and anything sent from the workers’ compensation provider.
2. Contact the provider
Once you have everything put together, if your claim is denied, call the workers’ compensation provider. Ask them why your claim was denied. Often, it could be a simple paperwork error, such as needing to file additional form or an incomplete form. Ask them what you need to provide for them to process your claim.
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.
3. File a claim
If your provider continues to deny your claim, you may have to speak with a workers’ compensation lawyer about filing an initial claim to contest the decision. The claims process works differently in each state, but most states follow the same general system.
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.
4. Appeal the hearing
The hearing is not the final step in the process. If unsuccessful at the hearing, you might be able to appeal to the administrative Board of Appeals: a panel of members that hear appeals from administrative hearings. Like the hearing, there are specific rules and procedures that must be followed. The Board of Appeals will issue a ruling based on the nature of your case.
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.
Consider hiring an experienced workers’ comp lawyer near you
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.
