The Most Common Reasons Claims are Denied and What You Can Do About it – Tips from a Wisconsin Workers’ Compensation Lawyer
If you suffered an injury on the job or were diagnosed with a medical condition due to the nature of your work, you may be considering filing a claim to receive workers’ compensation benefits.
While most employers have some form of workers’ comp insurance in place, what happens if your claim is denied? A denial can be incredibly frustrating, especially when you need financial assistance to account for any surgery, physical therapy, or lost wages you experienced. However, a denied claim is not always the end of the road.
The Wisconsin workers’ compensation lawyers at Fitzgerald & Bomier can help you understand why your claim was denied and how to move forward.
Three Common Reasons Claims are Denied
Insurance companies are known to actively look for reasons to deny your claim. If they have any doubt about the legitimacy of your claim, chances are they will be quick to deny it. Below are some of the most common reasons why insurance companies deny workers’ comp claims:
1. Missed Deadlines
After suffering an injury at work, there are several steps that you and your employer must take in order to receive benefits.
- Notify your employer of your injury or illness immediately.
- Seek any necessary medical treatment. Hold onto all relevant medical records and bills.
- It is your employer’s responsibility to notify their workers’ comp insurance carrier of your work-related injury or illness. The insurance carrier should then report your claim to the Wisconsin Workers’ Compensation Division.
For each of these steps, there are certain time limits in the state of Wisconsin. For example, any work-related injury or illness must be reported to your employer within two years of the accident or discovery of the illness. Furthermore, your employer is required to submit your claim to their insurance carrier within seven days after knowledge of the injury. If these deadlines are missed, it can hinder your eligibility for benefits.
For more information on the deadlines to file a claim in Wisconsin, visit the Wisconsin Department of Workforce Development.
2. Employer Disputes Your Injury
Employers may deny that your injury is work-related by claiming that it happened while you were off-duty or that it was the result of your own misconduct or reckless judgment. Employer disputes can disqualify you from workers’ comp benefits.
In order to argue against an employer dispute, you’ll need evidence, such as witness statements and a doctor’s report, to support your claim.
3. You Left Your Job Before Filing Your Claim
Insurers tend to deny claims that are filed after an employee was fired, laid-off, or quit. If you left your job before getting around to filing your workers’ comp claim, it will be challenging to prove to the insurer that you are entitled to benefits, even if you did suffer a valid work-related injury/illness. This is another reason why you should notify your employer immediately after your accident and ensure your claim is filed.
If you reported your injury within the specified timeline but were fired or let go before your claim could be resolved, it is in your best interest to consult an attorney. Keep in mind that it is illegal for an employer to fire you solely because you filed a workers’ comp claim.
These are three of the most common scenarios behind denied workers’ comp claims, however, there are plenty of other possible reasons your claim could have been denied.
Appealing a Denied Claim
If the insurance company denies your claim, you will receive a denial letter that should include the reason for their decision and information on how to appeal. While this can be discouraging, an initial denial doesn’t always mean that you aren’t entitled to benefits.
If you would like to challenge your denied workers’ comp claim, you will need to appeal. If the denial was due to a simple issue, such as incomplete paperwork or lack of a supporting document, disputes can possibly be settled informally between the insurance company and the injured party.
However, if a quick solution cannot be reached, you will need to request a hearing in front of an Administrative Law Judge (ALJ). After reviewing all relevant information regarding your claim, the ALJ will make a decision. If you believe the ALJ’s ruling was incorrect, there are additional levels at which you can further appeal.
While you are not required to do so, it is extremely valuable to have an attorney present at the hearing to appeal a denied claim. Hiring an attorney who is experienced with this type of legal proceeding will help ensure that your medical records and all other evidence supporting your claim are appropriately presented to the judge.
Why You Need a Lawyer
If your claim was denied and you’re considering filing for an appeal, speaking with a workers’ compensation attorney as soon as possible will be in your best interest. Appeals consist of complex legal procedures that will be very difficult to handle without the advice of a legal professional.
An attorney can review your claim and determine if you have the grounds to appeal. If so, they can help you prepare a strong case and speak on your behalf at the hearing. Many injured employees lose out on their right to benefits simply because they missed deadlines or didn’t understand the appeals process. You can avoid these common mistakes by having a knowledgeable lawyer on your side.
At Fitzgerald & Bomier, we have dedicated our practice to the needs of injured workers. Our Wisconsin workers’ compensation lawyers have over 35 years of experience in the Fox Valley and throughout Northeast Wisconsin. If you’ve suffered an injury or illness in the workplace, but your initial claim was denied, don’t lose hope. Call our office today at (800) 928-2667 or fill out our contact form to schedule a free consultation.