7 Steps To Take If Your Workers’ Comp Claim Is Denied in Georgia
You’re already dealing with the pain of a workplace injury and all the associated costs. Now, you find out your workers’ comp claim is denied.
You need to be compensated for medical treatment and income benefits, but that won’t happen if your workers’ comp claim is denied.
This adds even more stress to an already stressful situation.
Before you panic and think all is lost, you need to understand that it is common for a workers’ comp claim to be denied before it is approved.
For instance, as of September 2021, the Division of Energy Employees Occupational Illness Compensation (DEEOIC) reports 3,831 claims in Georgia. Of those, 2,029 were denied and 1,802 were approved.
More claims have been denied than approved.
Unfortunately, this is pretty common across the workers’ compensation insurance industry. Have you found that your workers’ comp claim is denied?
According to Lockton, “Workers’ compensation denial rates are up 20 percent.”
Because insurance companies care more about profit than people!
As much as we’d like to believe our insurance companies will do the best thing for us, they are much more interested in saving money, which is why your workers’ comp claim is denied.
They don’t want to give money away.
That means insurance companies use any possible reason to deny a workers’ comp claim.
Reports have shown that, more often than not, a denied workers’ comp claim ends up being paid – usually through settlement.
Lockton’s report claims, “While some of these denials are sustained and do not pay out, Lockton Analytics found that on average, 67 percent of initial denials convert to paid claims by 12 months. Think about that for a minute: on average, more than two out of three denied claims will pay out!”
Distinguishing between Types of Denials
The first thing you need to do is understand the type of denial that has been issued when your workers’ comp claim is denied.
The first type is an outright denial of the claim as a whole. In this case, it means the insurance company has denied there was an accident and/or injury and refuses to extend workers’ comp benefits.
The second type is a denial of a certain part of the claim, such as denying covering the costs of a specialist.
Both types prevent workers from receiving the benefits they deserve.
In addition, it is important to understand that you can file for a hearing in front of an administrative law judge if any part of your claim has been unfairly denied, such as your weekly wage, medical bills, or the disability finding (i.e., stating you are partially disabled when you are totally disabled).
No matter the case, you have a right to seek a clear reason for the denial and to request a hearing in front of an administrative law judge with the State Board of Workers’ Compensation to get your benefits.
There is hope even if your workers’ comp claim is denied. Here are the steps you need to take to get it approved or settled.
1. Don’t Give Up
The first step to take if your workers’ comp claim is denied is to choose to fight.
Don’t simply accept the denial and go back to work – especially if you are physically unable to work.
Keep in mind that it is common for insurance companies to deny workers’ comp claims initially.
Moreover, most of the claims that are initially denied are eventually approved or settled.
2. Consider Common Reasons a Workers’ Comp Claim Is Denied
After receiving word that your workers’ comp claim is denied, take time to review the common reasons claims are denied and see if your claim falls into one of these categories.
- Missed deadlines. Under Georgia workers’ comp law, if you did not notify your employer of the injury or file a claim within 30 days, you may lose your benefits.
- Not job-related. To qualify for workers’ compensation benefits, the injury must occur while you were working. If you are injured outside of work, this claim may be denied.
- Employer dispute. If your employer does not believe you were injured on the job or disputes the extent of your injuries, he or she can dispute the claim.
- Misconduct. If your employer thinks you were injured while under the influence of drugs or alcohol or if they claim you failed to follow safety rules, your claim may be denied.
- Not serious enough. Some workers’ compensation insurance companies may deny a claim because they do not think the injury is serious enough to warrant workers’ comp benefits.
If your claim falls into one of these categories, you will need to file for a hearing.
3. Hire an Experienced Workers’ Comp Attorney
At this point, it is wise to hire an experienced workers’ compensation attorney that understands the ins and outs of Georgia workers’ compensation law when your workers’ comp claim is denied.
For instance, many people find it helpful to work with a workers’ comp attorney from the very beginning of the process because handling a claim on your own can be very challenging.
This area of the law involves complicated forms, and it is easy for someone who is not experienced to get the forms, their significance, and any filing deadlines confused (which will get your claim denied).
An experienced workers’ compensation lawyer will know which forms to file, how to appropriately complete them, and when to file them to ensure you receive the benefits you deserve.
Now, add in filing for a hearing in front of a judge, and you have even more reason to hire an experienced workers’ comp attorney.
In addition, once litigation begins, the insurance company will have a chance to depose you and to ask probing background questions along with questions about your accident, injuries, and limitations.
Even if you win in front of the judge, the other side can then appeal the case to the Appellate Division, thus extending the delay in receiving benefits.
You don’t want to go through the litigation and appeal process without someone knowledgeable on your side.
4. File a Request for Hearing
At this point, you are ready to begin the litigation process.
You are required to file a Request for Hearing with the Georgia State Board of Workers’ Compensation.
According to the Georgia State Board of Workers’ Compensation, “You need to complete and file a WC-14, with the State Board of Workers’ Compensation and send a copy of the form to your employer and their workers’ compensation insurance carrier.”
This may be a little confusing because the WC-14 can be used both to file a Notice of Claim (at the beginning of the process) and a Request for Hearing (to start litigation). You just check different boxes on the form.
After you file the form, the State Board will schedule a hearing.
5. Prepare for the Hearing
Like a traditional trial in front of a judge, a workers’ compensation hearing gives you the opportunity to present your case.
You will tell the judge why you are entitled to receive workers’ compensation benefits, as well as present evidence (such as medical records and witness statements) supporting your case.
This also means the insurance company tells the judge their reasons for denying your claim, as well as getting the opportunity to cross-examine you.
After all the evidence has been presented, the judge will make a decision (but it won’t be the same day).
6. File for an Appeal with the Georgia State Board of Workers’ Compensation Appellate Division
If the judge from the workers’ compensation hearing denies your claim, you then file an additional appeal with the State Board’s Appellate Division.
While you cannot present any new evidence, your case will be heard by three members of the division rather than one judge.
In this case, you and the insurance company both file a brief and are given 5 minutes to argue your case in front of these three members.
7. Appeal through the Courts
If your workers’ comp claim is denied by the State Board’s Appellate Division, you can continue to move up the ladder and appeal with the Superior Court.
At this point, there is no new evidence presented or hearings.
The Superior Court will review all the previous case materials to see if your claim was wrongfully denied on the basis of law.
If your claim continues to be denied, you can appeal to the Georgia Court of Appeals, which will review all the previous evidence again.
Likewise, if you win, the other side has the same opportunities to appeal as well.
We cannot stress the importance of hiring an experienced workers’ compensation attorney to help you navigate the complicated appeals process.
If you’ve been injured on the job, contact us today for a free, no-strings-attached consultation.
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