Workers’ Compensation Claims

Employers are legally required to possess workers’ compensation in most states. Workers’ compensation is a program run by the U.S. Department of Labor that supports employees who are injured while at work. An employee who develops an occupational disease or disability from their job is privy to wage replacement, medical bill coverage, and vocational rehab.

According to EMPLOYERS, the most common workers’ compensation injuries are:

  • Lacerations
  • Burns
  • Sprains and Strains
  • Contusions
  • Fractures
  • Eye Injuries
  • Cumulative Trauma

These injuries can be obtained from a variety of work accidents such as slips, trips, falls, crashes, and motor vehicle crashes. In addition to sudden accidents, some work injuries happen slowly over longer periods of time. These can include injuries from repetitive motion, such as tendinitis in the shoulder or elbow. Additionally, there are illnesses that can occur from exposure to hazardous chemicals or stressful conditions, such as heart attacks, cancer, or hearing loss.

Your Claim Was Denied. Now What?

The last thing you want to deal with while recovering from a work injury is a denied insurance claim. This frustration only amplifies the stress, lost time, and lost money that is resulting from this incident. With workers’ compensation claim denials on the rise, it’s important to ensure that your claim denial was fair and valid. Your first step will be to try and determine why your claim was denied, and whether or not the reason is legitimate.

Legitimate Reasons

In order for a workers’ compensation claim to be processed, it needs to meet certain criteria. Some of the lawful reasons that a claim may be denied include:

  • The claim exceeds the policy coverage
  • Too much time has passed since the incident
  • Inconsistent reports from the victim
  • Illegal drugs were found in the victim’s system
  • The claim was filed after you were fired
  • The law was broken during the incident
  • The victim didn’t receive a medical evaluation

Bad Faith Reasons

Unfortunately, although they are hired to protect you in an emergency, insurance companies have been known to prioritize their own profits over their customers. When an insurance company is being dishonorable or not delivering what they promised, it’s called acting in bad faith.

Some examples of bad faith in workers’ compensation claims include:

  • Denying a claim with no explanation
  • Delaying payment on a valid claim
  • Unreasonable demands for proof
  • Failure to thoroughly investigate
  • Underpaying on a claim
  • Failure to communicate or provide documentation
  • Canceling or changing the policy
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Due to the complexity of insurance, it can be difficult to tell whether or not your insurance company may be acting in bad faith.

Next Steps

If you believe that your insurance company may be acting in bad faith, you can first make a report to your state. For example, if you live in California, you can start with this guide from the Department of Industrial Relations. Filing a complaint through your state department’s website is the first step in appealing a denied claim.

Next, file an application for adjudication of the claim. You will need to file this in the same county where you sustained the injury. Once processed, you will be provided with a case number. You can then request a hearing in front of a judge, which is called a mandatory settlement conference. Make sure to have an experienced attorney with you at the hearing, since the claims administrator will also have an attorney present. The case will either be settled at this hearing or will move forward to a trial.

If a trial occurs, make sure to have all relevant documentation prepared. After presenting evidence to the judge at trial, they will provide their decision in writing through the mail in 30 to 90 days. If either party wishes to dispute the judge’s decision, they can file a petition.

Contact a Workers’ Compensation Lawyer

Your most important step during the appeal process will be to speak with an experienced workers’ compensation bad faith lawyer. They will be able to determine whether or not your case involves bad faith. If it does, having an attorney on your side will be extremely beneficial. They will walk you through the complex process of filing a claim against your insurance company and will ensure that you recover the damages that you’re owed. Most law firms work on a contingency fee basis, meaning that you don’t pay them unless they win your case.