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December 15, 2021
After you have filed your workers’ compensation claim, you are anxiously awaiting the decision about whether you can receive these crucial benefits. In many cases, you will get the good news that they approved your benefits. However, in a growing number of cases, initial claims have been denied. When you fight this denial through an appeal, you have a good chance of overturning the insurance company’s decision. First, you must get the help of an experienced attorney.
What you do, both after injury and during the claims process, can determine the benefits you receive. Mistakes can be costly, and a legal professional can help you avoid the common errors that people make that may jeopardize their benefits. In the meantime, you should be very careful about meeting all deadlines and following all requests for information and paperwork.
When insurance companies deny workers’ compensation claims, you must either provide more information or fight the denial.
Here are five common reasons why insurance companies deny a worker’s compensation claim:
Denials can happen. Some studies place the rate of denial between seven and 25 percent. It does not matter that most claims end in approval. If your claim results in a denial, you and your family face a difficult time.
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Insurers are much more likely to deny a claim that a specific accident didn’t cause. For example, if you discover years later that you have an illness due to exposure to toxic substances in your workplace, you can then receive benefits. However, insurance companies may question the connection between your injury and the workplace. The same holds when you suffer a repetitive stress injury, or your job worsens a pre-existing condition.
The insurance company will give you the reason for the denial. You will need to examine the reason and see if the insurance company was wrong. They may be basing the denial on the information that they have at the time. Alternatively, they can be erring on the side of protecting their interests over yours and trying to make your life difficult. While it is not always in an insurance company’s best interest to deny your claim, it is well within their regular course of business.
Denied workers’ compensation claims are hardly the end of the line for injured workers. The law allows people to challenge the denial. The insurance company does not get the final say about your case because they have no power over your legal rights. All they are is an intermediary that provides the policy that your employer purchases. While they make the initial decision, you can challenge it. Talk to a lawyer to see if you should do so in your case.
One study shows that nearly three in every four denied workers’ compensation claims eventually end with benefits. Just because the insurance company is not granting your claim right away does not mean that you should lose all hope. If your claim ends in denial, your first call should be to an experienced workers’ compensation attorney (if you do not already have one).
In some cases, your workers’ compensation denial may simply result from a misunderstanding between you and the insurance company. They may not have understood part of your application, or they may have misread something. Your lawyer might resolve some of these misunderstandings by simply communicating with the insurance company to clarify part of your application.
While an insurance company may be aggressive about denying claims, they also do not want you to successfully appeal your denial because it will cost them even more money. They may spend thousands of dollars on their own to pay legal counsel. Unlike you, they are not hiring a lawyer on a contingency basis. If they see a valid reason to approve your claim, they may do it.
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However, there are times when the insurance company just will not accept the fact that you suffered a work-related injury. The good news is that you still have a chance of getting the workers’ compensation benefits that you need. Arizona has a robust appeals process that gives you multiple layers of review by an objective judge not affiliated with the insurance company.
When you file a workers’ compensation appeal, you must keep a close eye on the timing. The entire process happens in a short time. You only have 90 days to request a hearing after your initial claim denial. You will get your day in court once you request a hearing with the Industrial Commission of Arizona’s (ICA) Claims Division. The ICA will send out a notice with the date of your hearing after it receives your request. This is an expedited process, so you must move fast.
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You can expect that the hearing will happen relatively quickly. The law recognizes that you need workers’ compensation benefits and will have trouble paying your bills without them. This is where the system understands your situation.
There is a legal process that unfolds before the hearing.
Here are four steps in the Arizona workers’ compensation process:
You must extensively prepare before you go into a hearing. Subsequent appeals will examine whether the initial hearing officer made a mistake with their decision. You may not get the chance to make your case from scratch. As a result, you must put your best foot forward the first time you go in front of an administrative law judge.
If the judge rules against you, it is not the end of the line. First, you can request that the judge reconsider their decision. They will issue a new ruling after re-examining the evidence. If that still does not result in benefits, you can go to the Arizona Court of Appeals, but you must file your case within 30 days after receiving the decision from the reconsideration. The Court of Appeals will consider the record and may ask for oral arguments in making their decision. You will not get to begin your case anew there.
The promising news is that many denials result in benefits. One study places the rate of denials converted to benefits at around 70 percent. This means that insurance companies either relent and approve the claims or lose the case on appeal. Many people wonder why they are so aggressive about denying claims because the appeals process costs these companies money, too. They must use their lawyers to represent their side of the case at a hearing. They may not want to go this far, given their costs.
This also shows that workers can and should challenge a decision that seems arbitrary and unfair. This is not to say that insurance carriers and employers should accept every single claim, but the high rate of overturning initial denials shows that insurance companies are perhaps even too strict with the roughly seven percent of initial claims that they deny.
Many of the 70 percent of people who ultimately received benefits hired an attorney after their initial denial. While the system allows you to challenge a denial, it works better for people who have an experienced attorney arguing their case.
An attorney can get to the bottom of your case in a hurry and:
You do not want to take on the insurance company on your own. You only get one chance to engage in the appeals process, and you need to take your best legal shot. If you miss, you will not get the benefits that you desperately need. This is why you need a lawyer with knowledge and experience in workers’ compensation appeals. This is a specialized process with very high stakes.
The workers’ compensation claims process is vital to your physical and financial health. At stake is the money needed to pay for your treatment. Even though you will not receive your full paycheck, any money coming in is helpful when you cannot work. We understand how the process can cause stress and worry in your family and why a denial will be catastrophic. This is why we are here to use our knowledge of the system to fight for you.
A workers’ comp lawyer will immediately get to the bottom of your claim and the reasons for the denial. They will hone in on ways to strengthen your claim and counter the insurance company’s side of the story. This is a very time-sensitive process and one that you cannot delay. If your workers’ compensation claim is complex, you should consider hiring an attorney before you file it, so you can make the strongest possible claim. If you receive a denial, you must act quickly.
Here are some tips for how to put yourself in the strongest position for your workers’ compensation claim and appeals process:
Look for lawyers with extensive experience with the workers’ compensation process someone who knows the arguments to use and effective strategies to convert your denial to granted benefits. You want someone who is here for you every step of the way to make the stressful and confusing
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