Workers' Compensation Disputes
Federal and state law provides that if a worker becomes ill or is injured on the job, he/she may be entitled to medical care, lost wages, rehabilitation costs and other worker's compensation benefits. Yet legitimate workers' compensation claims are routinely undervalued, improperly investigated and wrongly denied because of human error or even bad faith.
If your workers' compensation claim was denied, you disagree with the evaluation of your claim or you are otherwise having problems with your case, you can dispute your case with the insurer, the workers' compensation board or even in court. However, to maximize your chance of a successful outcome you should have a workers' compensation attorney shepherding your claim through the proper channels.
Denial of Workers' Comp Claims
In a typical workers' compensation case, an employee who is ill or injured on the job files a claim with his/her employer and sees an approved physician for evaluation and treatment. In most cases, the insurance company (or other insurer which may be the government or a self-insured employer) will investigate and make a determination of benefits within 30-60 days. At that point, the employee should begin to receive medical and financial assistance enabling a speedy recovery and return to work. All too often this is not the case.
There are many reasons part or all of a workers' compensation claim can be stalled or denied. The insurer may claim:
- The injury or illness did not occur on the job
- Suspicion of fraud
- Pre-existing condition
- The employee failed to file a timely claim
- The employee did not submit to timely physical examination
- Lack of evidence
However, workers' compensation insurance companies do make mistakes, and sometimes they act in bad faith. For example, if your claim was denied citing a pre-existing condition, it may have been wrongfully denied. In fact, when a pre-existing condition is accelerated or exacerbated by an on-the-job illness or injury, most employees are entitled to workers' compensation benefits.
Other Workers' Comp Disputes
Disputes can arise at any point in the claim process. Thus, even if your workers' compensation claim is approved, you may not agree with the type, amount and duration of the benefits or you might be having problems collecting your benefits. Specific reasons you may need to launch a dispute might include:
- You did not receive the tests needed to properly diagnose your injury.
- The company approved doctor is not qualified to treat your specific illness or injury.
- Your benefits were calculated based on a lower wage than you actually earn.
- The insurer refuses to recognize some aspects of the injury.
- You are not receiving your temporary or permanent disability checks (to make up for lost wages), or they are being paid erratically.
- You are forced to go back to work before you have recovered sufficiently.
- You are permanently disabled but your evaluation for permanent disability resulted in very low, or a zero, impairment rating.
The easiest and quickest way to resolve some of these problems is for you (and your lawyer) to speak to the case manager or other insurance company representative directly. If the problem still cannot be resolved, you may need to initiate a formal dispute/appeal.
The Dispute/Appeal Process
If you are unable to resolve a disagreement with the insurer directly you will need to escalate the dispute. Dispute resolution options will vary depending on the insurer, the jurisdiction and the other facts specific to your case. Below are some of the common methods for dispute resolution:
- Mediation or other informal dispute resolution. More and more states have adopted informal dispute resolution procedures such as mediation. Mediation is a voluntary process in which a neutral third party helps employers, employees and insurance carriers resolve workers' compensation disputes to everyone's satisfaction without the need for litigation.
- Disputes/hearings. If a claim still cannot be resolved, a formal hearing is usually the next step. These hearings are similar to a trial in court of law but are conducted instead by the state workers' compensation board.
- Appeals. If a party is still not satisfied with the workers' compensation claim, the claim can usually be appealed in state court.
The procedures vary by state and there are usually limits on your time to file a dispute. It is advisable to speak with an attorney who will be able to determine which procedures apply to you.
Workers' Compensation Attorneys
If you are having problems getting workers' compensation benefits, consult an attorney who is experienced in disputing workers' compensation claims and will fight for your rights. A workers' compensation attorney is best qualified to resolve the dispute and get you the medical and financial assistance that is lawfully yours.
If you received treatment from a doctor or therapist for a work-related injury or illness, you are entitled to a copy of all of the records, notes and reports created by any and all treating physicians.