Are you dealing with a denied workers’ compensation claim? Whether from a workplace accident or an occupational disease, if you have suffered an acute or chronic injury related to your work, you might be entitled to workers’ compensation benefits.
Insurance company representatives for workers’ compensation are incented to offer you the smallest settlement they can. So, no matter how friendly, sympathetic, and congenial an insurance company representative might seem, remember that he or she is definitely not on your side. In fact, quite the opposite is the case. Insurance company representatives aggressively deny or limit claims because they are betting you will not hire legal counsel and assert your rights.
This blog entry uses an FAQ format to explain what you need to know about filing a claim for workers’ compensation insurance and/or a denied workers’ compensation claim. Among them:
What is workers’ compensation insurance?
Who pays for worker’s compensation insurance?
What is covered by workers’ compensation insurance?
How is a workers’ compensation claim filed?
What are some occupational diseases covered by worker’s compensation insurance?
Can you sue your employer for negligence?
What are some reasons that workers’ compensation claims are denied?
What should I do about a denied workers’ compensation claim?
What is workers’ compensation mediation?
What is a workers’ compensation administrative hearing?
How much does it cost to hire a workers’ compensation attorney?
1. What is workers’ compensation insurance?
Workers' compensation is a form of insurance providing medical benefits and lost wage replenishment to employees injured during the course of their employment. In short, it is designed to provide you benefits if you are injured at your job, or contract a disease because of it. And although you would not know it, given the rhetoric that surrounds “workers’ comp,” the program was developed to protect both employees and employers (see source). However, please keep in mind employers are NOT required to carry workers’ compensation insurance.
For employees, workers’ compensation provides medical benefits and wage replacement if you have suffered a job-related injury or illness—without the time, expense, and psychological stress of having to sue your employer.
For employers, workers’ compensation protects them from bankruptcy if an employee were to be significantly injured and successfully sued for an amount that leaves the employer insolvent, being unable to pay the suit, and consequently out of business.
This is a trade-off. You enjoy assured limited coverage against workplace injuries and illnesses. But you relinquish any recourse outside the workers’ compensation program. In other words, you cannot sue your employer for the tort of negligence, with some exceptions (see 6 and 10).
2. Who pays for worker’s compensation insurance?
Workers’ compensation insurance is paid for solely by your employer. There is no salary deduction on your paystub for workers’ compensation as there might be for your healthcare or dental coverage.
Your employer pays for worker’s compensation either by buying an insurance policy from a “competitive” workers’ compensation state fund or from a private insurance company. In most states, an employer can opt for one or the other.
Whether your employer handles workers’ compensation through a state fund or a private corporation, remember that both are nonetheless insurance companies—and they act that way. This means they will do whatever they can within the law to deny or reduce your claim because that is the way insurance companies increase their profits. This includes denying specific benefits or entirely rejecting a claim for technical errors or “lack of documentation.”
3. What is covered by workers’ compensation insurance?
Workers’ compensation insurance covers your medical expenses including medications, emergency surgeries, and hospital visits. Lost wages are partially covered if you need time away from your job to recover from your work-related illness or injury.
You are entitled to disability benefits if you are partially or permanently disabled from your work-related injury or illness. Costs for ongoing care (e.g. occupational therapy) are also covered.
If your loved one is killed in a job-related accident, death benefits might include funeral costs and survivor benefits for you and your family.
Some states might limit the duration of workers’ compensation benefits, which can be anywhere from three to seven years.
Workers’ compensation payments and benefits are not taxable. But if you are receiving retirement benefits, social security disability insurance, or supplemental security income, then a portion of your workers’ compensation might be taxable (see source).
4. How is a workers’ compensation claim filed?
The first step is reporting your work-related illness or injury to your employer. This should instigate your employer to notify the state or private insurance provider. Your injury will need to be reported to the Occupational Safety and Health Administration OSHA if it is severe.
You might be required to appear before a workers’ compensation board to make your case for receiving benefits. It is best not to travel this road alone. You should retain the services of an experienced workers’ compensation attorney.
5. What are some occupational diseases covered by worker’s compensation insurance?
Occupational diseases are illnesses or conditions that develop over time, caused by your work‑related activities. Some examples of these include:
Repetitive Strain Injury (RSI). Occupations requiring you to make repetitive motions, or that involve repetitive traumas, can cause significant injuries to muscles, tendons, and ligaments. Affected areas are usually your thumbs, fingers, wrists, elbows, arms, shoulders, or knees.
RSI can result in chronic pain, limited range of motion, and other conditions that affect your ability to earn a living and degrade your quality of life (see source). Most notorious among occupational diseases is repetitive heavy lifting, which can lead to low back pain.
Exposure to chemicals and dust. Silicosis is a kind of pulmonary fibrosis caused by inhaling tiny particles of silica, which is a mineral found in sand, quartz, and other rocks. Silicosis commonly affects construction and mining workers. Mesothelioma is a cancer type that occurs in the thin layer of tissue that covers most of your internal organs, called mesothelium. Inhaling asbestos is a major cause.
Hearing Loss. Hearing loss is suffered by workers who have been exposed to high decibel levels in the workplace without adequate ear protection. There are three types: Conductive hearing loss involves the outer or middle ear; sensorineural hearing loss involves the inner ear, and mixed hearing loss is a combination of the two (see source).
6. Can you sue your employer for negligence?
Yes. But it’s difficult to do. Especially since the workers’ compensation program is specifically designed to avoid litigation, the logic being that for many employers, being sued for a significant amount would simply force the company into bankruptcy. Then, your successful negligence suit would only place you on a list of creditors. In effect, out of tort and into bankruptcy court.
To prove negligence, you have to demonstrate that your employer caused you to work in a certain position or execute certain tasks that the company knew to be dangerous, or for which you were inadequately trained, or unknowledgeable. Such negligence can be allegedly consequent to practices in hiring, retention, supervision, and/or training.
It is relatively easy to trace negligence to some practices as opposed to others. E.g., hiring negligence would be pretty obvious if you did not have the proper knowledge, training, and/or license to perform your duties. In contrast, training negligence would be harder to pinpoint, as you might have been trained by many different coworkers, supervisors, managers, etc.
7. What are some reasons that workers’ compensation claims are denied?
It is important to know the legitimate reasons for a denied workers’ compensation claim so that you can recognize bogus ones. But remember that even legitimate reasons can be inappropriately applied by your employer or the insurance company to stifle your case. That said, here are some situations that your work injury lawyer will help you challenge:
A. Your injury did not occur on the job. You must have sustained your injury while you were performing your job duties in order to be eligible for workers’ compensation benefits. But this is not so cut‑and-dry. Consider:
If you work in a supermarket and damaged your knee while stocking shelves, you have a viable case. But if it happened during your lunch break or commute to work, you are most likely not eligible for benefits. However, if you were not at the supermarket but, for example, were delivering groceries when you damaged your knee, you might have a case.
Instances such as these highlights the advisability of securing a work injury lawyer. Especially since both the insurance company and your employer have a vested interest in proving that you were not at work when you got hurt.
B. You did not notify your employer on time that you were injured. It is vital that you inform your employer about an on-the-job injury as soon as you can. This is because there are time limits specific to the workers’ compensation claim process. You can damage your case in a number of ways by late reporting of your injury. Among them:
Too much time may have elapsed for your employer to conduct an accident investigation, which is important for a workers’ compensation case to succeed.
The insurance company and your employer might cite your late reporting as evidence that you were not actually hurt on the job. I.e. if you were hurt at work, you would have made it known sooner rather than later.
C. Your injury is traceable to a pre-existing condition. If you have had your injury or illness prior to beginning your job—and your duties did not make your injury or illness worse—you are typically ineligible for workers’ compensation benefits.
This is a favorite insurance company argument to deny your claim. But bear in mind that workers’ compensation claims are complex and the rules ambiguous: another reason why you should retain a qualified workers’ compensation attorney rather than go it alone.
D. You were not seen by an approved medical provider. Per workers’ compensation rules, both the insurance company and your employer retain the right to stipulate an approved list of physicians from whom you can receive treatment for your workplace injury.
As these physicians are effectively having lucrative business steered to them by the insurance company and your employer, they might have a tendency to minimize your injury, which can diminish your potential workers’ compensation benefits. E.g. An “approved medical provider” reviews your medical records and disputes your physician’s evaluation of your condition—without ever examining you: yet another reason why you should seek counsel from a qualified work injury lawyer.
E. You never sought medical treatment. You should seek medical attention ASAP if you believe your injury is claim worthy because you will need the medical records to support your case. If you fail to see a physician and later file a claim, the insurance company or your employer might allege that you are feigning injury to get benefits. Also, if you were to be fired or laid off since being injured, and you have yet to seek medical attention, your employer or the insurance company might make a convincing case that you are filing a claim to seek revenge.
F. You did not file on time. A qualified workers’ compensation attorney will ensure that your paperwork is filed on time. There are time limits and deadlines specific to workers’ compensation claims that you must meet, even for slowly-developing injuries, such as repetitive strain injury (RSI). If you fail to file the necessary paperwork within the stipulated time limits, your claim will likely be denied.
G. You were under the influence of drugs or alcohol. Your employer has the right to require that you be tested for alcohol and drugs when you are seen by a physician because of a workplace accident. If results demonstrate that you were under the influence when the injury happened, you will have a denied workers’ compensation claim.
H. Fighting, roughhousing, horseplay or practical joking caused your injury. Injuries incurred during such “extracurricular” activities are definitely not eligible for workers’ compensation benefits, and you will have a denied workers’ compensation claim.
I. Your claim is disputed by your employer. Your employer might fear that the company’s premiums for workers’ compensation insurance will rise if your claim for benefits is successful. Thus, your employer might argue that the details of your case are inaccurate, that you were not at work when you were injured, or otherwise toil to dispute your claim. For these reasons, if you are hurt on the job, you should inform your supervisor and your coworkers as soon as possible—especially if there were no witnesses—and contact a work injury attorney.
8. What should I do about a denied workers’ compensation claim?
If your workers’ compensation claim is denied in whole or in part, the resolution might be as easy as a phone call. Your first task is to call the claims manager with whom you have been dealing. Denials sometimes result from a misrepresentation, clerical error, or some other mistake. Be sure to have dates, times, and other documentation ready when you call.
If the phone call provides no relief, you should contact a workers’ compensation attorney immediately. Once an attorney becomes involved, it is not unusual for insurance companies to change their position and allow claims.
Meanwhile, the denial letter you received likely contains information about filing an appeal. This will include what steps to take and how long you have to complete them. Depending on your state, the deadline ranges from 30 to 90 days. The clock is ticking!
If you believe your worker’s compensation claim has been denied because of fraud, administrative error, or some other irregularity, your work injury lawyer will file a complaint with the U.S. Department of Labor administrative office for workers’ compensation. This is not something you want to try without an attorney. Consider:
Once you file an appeal, you and the insurance company are now legal adversaries.
The burden is upon you to prove that you were injured on or for your job.
You must be easily conversant with the details of your case and have adequate documentation.
You will need a second medical examination to refute claims about your injury.
Workers’ compensation laws differ from state to state. You need to know the applicable law.
Different judges require different procedures.
There might be more than one level of appeal in your state.
9. What is workers’ compensation mediation?
The first step after appealing a denied workers’ compensation claim is mediation (aka “settlement conference”), which is an informal negotiation wherein you and the insurance company try to come to an agreement with the help of a mediator.
This does not involve witnesses; no one will “testify” under oath, and the mediator cannot force a decision for or against you.
If mediation is not successful, your claim will go to a hearing conducted by an administrative judge. Hiring a qualified workers’ compensation attorney is highly recommended (See 10).
10. What is a workers’ compensation administrative hearing?
At your workers’ compensation administrative hearing, you will need to present evidence (including your medical records), call witnesses, and accurately cite the relevant law. Once done, it will likely be many weeks before a decision is made.
If the administrative hearing goes against you, you can file something called a “board appeal.” In some states, this will be in front of a workers’ compensation appeals board. In others, a panel of judges.
If your board appeal is unsuccessful, in most states you can file a lawsuit through the courts, and the decision will be made by a judge or a jury. This might take years and can even lead to more appeals.
Again, it is crucial to secure competent legal counsel in the form of a work injury lawyer.
11. How much does it cost to hire a workers’ compensation attorney?
Galindo Law does not charge any upfront or out-of-pocket fees to help you with a denied workers’ compensation claim. We are only paid a percentage of the settlement we are able to secure for you. By working with Galindo Law, you incur zero financial risk.
Or, if you prefer, email us. And thank you for reading our blog!