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How to Appeal a Workers’ Compensation Claim

By Kenton Koszdin on October 8, 2018 | In Workers Compensation

How to Appeal a Workers’ Compensation Claim

If your Workers’ Compensation Claim has been denied, there are several steps to go through when it comes to an appeal of the decision. Depending on the reason for the denial, the process may be short or it could be lengthy. To receive any Workers’ Comp benefits to which you may be entitled, it is important to know what steps you need to take to appeal the denial of benefits.

Common Reasons Your Workers’ Compensation Claim was Denied

There are typically four reasons your claim could be denied. You may have more than one reason as well. It is important to understand these so you know what steps to take when filing an appeal. If you still need to file your claim, understanding why it may be denied can help you create a solid case that has fewer chances of being denied.

What are the four most common reasons your Workers’ Compensation Claim may be denied?

You Missed a Deadline

This is one of the most common reasons for denial of Workers’ Comp claims. Not only are there deadlines placed on when your initial claim needs to be filed, but if more information is requested or you have appointments with a provider for treatment, it can be considered a missed deadline.

Questions Regarding “Work Related” Injuries

Not all injuries that occur on the job are easily seen as work-related. Your Workers’ Comp claim adjuster may have questions about the validity of the claim. It is important to give as much evidence as possible that the injury or illness was caused by your work environment.

It is a Certain Condition

Not all work-related injuries or illnesses are considered appropriate for a Workers’ Compensation claim. If your condition isn’t covered, or didn’t happen at work, workers in the state of California may qualify for State Disability Insurance (SDI). However, most workers don’t qualify for both.

You Are No Longer Employed by the Employer

Whether you quit voluntarily, are laid off, or were fired, your Workers’ Compensation claim may be denied if you are no longer employed by the person or company that was a direct cause of your injury or illness.

Receiving Your Workers’ Comp Denial Letter

The denial letter you receive from your Workers’ Compensation claim will have a lot of very important information. The reason(s) you were denied as well as what options you have, whether you choose to let the denial stand or wish to appeal it. The reasons may be related to a missed deadline by your health insurance or even your employer, which can be relatively easy to show.

If you are denied, the letter you receive will also let you know who you can contact, whether it is your employer, your insurance company, or even the claims adjuster who made the decision.

How to Appeal a Workers’ Compensation Claim Denial

You will most likely need to see a qualified medical examiner, or QME, to have your work-related injury or illness verified. The claims adjuster can let you know which health care providers are registered as a QME. If you have hired a Workers’ Compensation lawyer, they can help in this process. Once a QME is found, they will be known as an AME, or agreed medical evaluator.

If there is a disagreement between what the employee and their lawyer see as a work-related injury and what the treating provider has testified, you can request an IMR. An IMR is an independent medical review by an objective provider.

Once you file an Application for Adjudication of Claim, you will be scheduled for a hearing. Your lawyer will want to attend this hearing as well. A judge will try to come to a decision that is fair regarding your case given the evidence you’ve presented. Even after your hearing, the judge may decide to uphold the original denial.

There is still another step you can take when appealing the decision. Once you’ve assembled all of your evidence proving the injury or illness was work-related, you can file a Declaration of Readiness to Proceed. This will force a mandatory settlement conference, or MSC. When you’ve received your denial from the hearing, you will need to go to trial. At this point, if you don’t already have a lawyer, you may want to hire one to help you file a Petition for Consideration.

There are many steps involved in a Workers’ Compensation claim appeal. Having an experienced Workers’ Comp lawyer can help you go through this process, possibly getting you the benefits you deserve after being injured on the job. If your Workers’ Compensation claim has been denied, contact the Koszdin Law Office today for a free consultation.

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