What Happens If My Workers’ Compensation Application Is Denied?

Every year, many legitimate workers’ compensation claims are denied—leaving injured workers without the money they need to pay their medical bills and support themselves.

How is this possible?

Filing a workers’ compensation claim is a complicated process, and even honest workers can find their claim denied for a variety of reasons. Here are just a few of them:

• The employer disputed the claim. For example, if there were no witnesses to the injury, the employer might not believe the injury happened at work. In other cases—like claims of a repetitive motion injury—the employer might argue that a previous condition—not the job—caused the injury.
• The employer looked for any reason possible to deny the claim, in order to avoid paying out benefits and to decrease insurance costs.
• The claim was not filed on time or was filed after the employee was fired or laid off. Insurance companies often assume that if a worker doesn’t immediately file a workers’ compensation claim, he or she must not really be hurt.
• The claim was not filed correctly. If the claim was filed incorrectly or included mistakes in the paperwork, it will be rejected.
• There are discrepancies in the employee’s story. If there are discrepancies between the claim and the medical records, the workers’ compensation insurer will be suspicious of the claim—even if the discrepancies occurred because of a perfectly normal memory lapse.
• The employee’s injuries are not covered by workers’ compensation. Some injuries are not severe enough to merit workers’ compensation benefits. Others—like psychological conditions—are not covered by workers’ compensation at all.

When you have been injured at work, you want to get workers’ compensation benefits as soon as possible. After all, you need that money: you’ve got bills to pay, and your injury might be keeping you from working.

If your claim is denied, it might seem like all hope is lost—but that’s not true. You have the option to appeal the decision.

After receiving notice that your claim was denied, you may want to consider contacting your employer or the Bureau of Workers’ Compensation (BWC). If the claim was denied because of a paperwork error or other small problem, it may be possible to clear up the mistake quickly. If the employer or insurer denied your claim for another reason, however, it will be necessary to appeal.

Your appeal must be submitted in writing to the Ohio Bureau of Workers’ Compensation. It must be submitted on the correct form and contain your name, the name of your employer, the claim number, the date on the claim rejection letter, and the reason for the appeal.

The BWC makes the initial decision to accept or deny a claim. Once a claim is appealed, the appeal goes before the Industrial Commission of Ohio (IC).

There are three levels for workers’ compensation appeals at the IC: district, state, and commission.

District hearings are held within 45 days of the date of the appeal. They take place at an IC customer service office closest to the injured employee’s house. The district hearing officer typically sends his or her decision within 7 days of the hearing date.

If you disagree with the district hearing officer’s decision, you may appeal to the state hearing officer. You must appeal within 14 days of receiving the district hearing officer’s decision. The state hearing will take place within 45 days of the date of the district hearing.

If you disagree with the state hearing officer’s determination, you have the right to appeal to commission. The commission may or may not decide to hear your case. If it does, the hearing will again take place within 45 days of the state hearing.

Finally, if the commission denies your claim, you may decide to take your case to the Ohio Court of Common Pleas. At this level, a judge will look at the facts of your claim and make a decision.

At every stage of the appeals process, it is important to convincingly make your case. You’ll need to bring all of the evidence you have related to your work-related injury, including medical records, witness statements, and other documents.

While legal representation is not required during the appeals process, it is recommended. (You can be sure that your employer will have a professional arguing on its behalf.) Having an experienced attorney on your side can help you increase your odds of success. A good attorney will help you gather the evidence to prove your case and will present a strong argument for approving your claim to the hearing officer.

If you are thinking of filing a workers’ compensation claim or need help appealing a denial, we’re here to help. Call Casper & Casper to speak with a qualified, knowledgeable workers’ compensation attorney about your options.

 

Sources:
Ohio Bureau of Workers’ Compensation
Ohio Bureau of Workers’ Compensation: Claims Hearing Process
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