Don’t give up if your workers’ compensation insurance claim is denied. Here’s how you can file and win a workers’ comp appeal.
If your workers’ compensation claim is denied by the insurance company, you have the right to appeal the denial.
Most states have a Workers’ Compensation Appeals Board (WCAB) to decide disputes raised by injured workers. After you file an appeal to dispute the denial, both sides will argue their position, usually at a hearing.
If the WCAB sides with the insurance company, you may still have recourse through your state’s court system.
Careful preparation and good legal advice are the keys to winning your workers’ comp appeal. Here’s what you need to know to get the insurance payout you deserve.
The Workers’ Compensation Appeals Process
On average, a workers’ comp appeal will take four to six months to complete, depending on the number of appeals you file and the time it takes a judge or court to issue a ruling.
Since workers’ compensation laws vary among states, the appeals process will depend on the state with jurisdiction over your claim. There are generally four steps in the appeals process.
1. Notice of Denial and Right to Appeal
The workers’ compensation appeals process typically begins with a claim denial letter from your employer’s insurance company.
The letter should state the reason why your claim is denied. Read the letter carefully so you fully understand the basis for the denial.
Your denial letter should tell you:
- When and how you can appeal the denial
- What documents must accompany the appeal
- The deadline for filing your appeal (usually between 30 to 90 days)
If your claim was denied because of an oversight, contact the claims adjuster to see if you can provide new evidence or correct any misunderstanding for reconsideration. If you can fix the oversight, the insurance company may accept your denied claim.
2. Filing an Appeal
Your appeal must be filed correctly and on time. Each state’s workers’ compensation system will have deadlines for claims and appeals.
A Workers Compensation Appeals Board (WCAB) is a division within a state’s workers’ comp agency. The division is responsible for hearing and deciding a worker’s first appeal from a denied workers’ comp claim.
After your appeal is filed, your case will be assigned to a workers’ comp administrative law judge, or another member of the state appeals board. You’ll be notified of the date and time set for the appeal hearing.
If you haven’t already consulted a workers’ compensation lawyer, now is the time. You can bet the insurance company will have corporate defense attorneys arguing against your claim.
3. Appearing at the Hearing
During an appeal hearing, denied workers can present evidence to help support their claim or show why the insurer was wrong in denying the claim in the first place.
Your employer’s insurance provider can also present evidence to support their decision to deny your claim.
4. Getting the Appeal Board’s Decision
After the hearing is complete, the judge will review the evidence and either affirm or overturn the denial. Judges typically write their decisions and send them to claimants within 30 to 90 days of the hearing date.
If the judge rules in your favor, you can expect the insurance company to begin processing your claim.
If your appeal is denied, the ruling should explain why the judge (or board) was not convinced you have a valid claim.
Filing a Second Appeal in State Court
Your first appeal will be through the state’s workers’ comp agency. If the denial of your claim is upheld, most states allow injured workers to file a second appeal in state court.
For example, according to Washington’s workers’ compensation laws, workers can appeal a claim denial with the Board of Industrial Insurance Appeals (BIIA). If the worker receives an unfavorable ruling, the worker can then contest the decision by filing an appeal with the state’s superior court.
If an employee loses in a lower state court, most states allow the claimant to appeal that decision with their state’s supreme court. Workers usually have to file this appeal within 30 days of the lower court entering its decision.
A state supreme court of appeals can decline to hear your case. If this happens, the judge’s decision in the lower court is final, and you have no other avenues to pursue an appeal.
When You Can File a Workers’ Comp Appeal
In many states, you can file for a hearing with the state Worker’s Comp Appeal Board if you have an active claim but have a dispute with the insurance company about your worker’s compensation benefits or injury settlement.
However, most appeals are filed because the insurance company denied an injured employee’s workers’ compensation claim.
Common reasons why an insurer may deny a claim:
- Inaccurate information: In some situations, you can resolve the issue with the insurance company before your claim gets denied.
- Late claim forms: All states have laws or deadlines on when injured workers must file a workers’ comp claim.
- Injury not work-related: Employees can only receive workers comp benefits for a work-related injury.
- Inappropriate conduct: An insurer can deny your claim if the injury took place because of inappropriate conduct like drinking, drug use, or horseplay on the job.
- Ineligible worker: Some workers, including independent contractors, volunteers, and farmworkers are ineligible to receive workers’ comp benefits.
If you disagree with the insurance company’s excuse for denying your claim, talk to an experienced workers’ comp lawyer as soon as possible to discuss the strength of your appeals case. Likewise, if your claim is being investigated, contact an attorney to protect your rights.
Preparing for a Workers’ Comp Appeal Board Hearing
A workers’ compensation hearing is conducted by the Workers’ Comp Appeals Board, where you can present evidence to challenge an insurer’s denial of your claim.
Plan to dress appropriately for the hearing. You don’t have to wear a business suit, but look nice. Don’t wear flip-flops or a tank top.
A judge oversees the hearing and makes the ultimate decision on the outcome of your case.
In addition to the judge, the following people are present at the hearing:
- Your workers’ compensation lawyer
- The insurance company’s lawyer
- A court reporter (to record the proceedings of the hearing)
A representative from your employer and the insurer may also attend the hearing.
Collect and Organize Your Evidence
The best way to prepare for your appeals hearing is to organize and review all of the evidence you’ll present to the judge. Your attorney will organize your evidence and go over it with you.
Helpful evidence includes:
- Medical records documenting your workplace injury
- Personnel and employment records to verify time away from work
- Reports by expert witnesses or medical professionals
- Paystubs or other records that substantiate lost wages
Prepare to Testify
It’s essential to review all the points you’ll testify on. Prepare to provide your testimony clearly and accurately. Your workers’ compensation attorney will help you get ready by asking you questions that may come up during the hearing.
When you testify during the hearing, don’t make up facts or exaggerate them. Always testify truthfully. If you don’t know the answer to a question asked of you, simply say, “I don’t know.”
You may be asked to testify about:
- How you were injured and the extent of your injuries
- The medical treatment you received for your injuries
- Whether you were able to return to work immediately after your injury
- The time you had to miss work because of your injury
- Your typical job duties and expectations as to work performance
Once you testify, the judge or the attorney for the insurance company may ask follow-up questions in light of the information you provided.
Depending on the facts of your case, other witnesses may testify at the hearing as well. For example, a co-worker that saw your accident may testify, as will the insurance company’s adjuster that denied your claim.
Once both sides present their evidence and testimony, the judge will take it all under consideration. You can expect to get the decision by mail within 30 to 90 days after the hearing.
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