What to Do If Your Workers’ Compensation Claim Is Denied
After being injured at work, workers’ compensation can prevent someone’s life from falling apart. Unfortunately, not everyone gets the help they need. With their workers’ comp claim denied, many people feel that they have no path forward. However, it is possible to appeal the decision and still have your claim accepted.
Reasons Workers Compensation Claim Is Denied
There are a number of reasons your claim may have been denied. These can include:
- Failure to Report: When it comes to workers’ comp claims, the statute of limitations in Massachusetts is 4 years. Failure to report your injury within this time limit will result in a denied claim.
- Failure to Seek Medical Care: Claims without an official diagnosis from a licensed doctor will usually be denied.
- Employer Disputes Claim: Your employer may claim your injury was not work-related. Some unethical employers may even do this when they know it is not the case.
- Insufficient Medical Evidence: If a doctor is unable to find sufficient evidence of your injury or condition, your claim may be denied. This happens often with injuries which are hard to prove, such as chronic back pain or headaches.
- Pre-Existing Condition: Your injury may be ruled as being caused by a pre-existing condition, not working conditions. This will cause your claim to be denied.
- Illegal Activities or Breaking Protocol: If it is found that your injury was caused while you were engaging in illegal activities during work or while you were not following the protocol you were trained to, your injury will not be covered by workers’ comp.
- Clerical Errors: If you made a mistake while filling out the required paperwork, or you missed a deadline for submission of said paperwork, your claim can be denied.
These are some of the most common reasons a worker’s compensation claim is denied. Your claim was likely denied due to one or a combination of these factors.
Workers’ Compensation Appeal
If you believe your workers’ compensation claim was wrongfully denied, you should appeal the decision. In Massachusetts, appeals are filed with the Department of Industrial Accidents (DIA). Here is an overview of the entire process.
Gather Evidence
In order to win your appeal, you will need evidence to back up your claim. Such evidence includes:
- Medical records documenting your injury, diagnosis, and treatment.
- Witness testimony from anyone who was present when your injury occurred.
- Documentation, such as a timesheet, showing you were at work when your injury occurred.
- Expert opinions from your doctors and other medical professionals.
- Bank statements or other financial documentation proving lost income.
The more of these things you have, the more likely you are to win your appeal and receive the workers compensation you’re entitled to.
File an Appeal
Once your claim is denied, your appeal must be filed within 30 days. To do so, fill out form 112 accurately. You will also need to pay a filing fee equal to 30% of the state average weekly wage at the time of the appeal. Mail your completed form 112 and the required fee to:
Reviewing Board Fee Processing
Department of Industrial Accidents
Lafayette City Center
2 Avenue de Lafayette
Boston, MA 02111
If you cannot afford the fee, you may also fill out and send form 112A, requesting that the fee be dismissed.
Appeals Process
The appeals process is relatively straightforward. The Reviewing Board will send parties a date on which their briefs are due. Your brief should include all evidence supporting your claim. After briefs are received, there are a few paths the process can take, these are:
- The Reviewing Board may choose to schedule oral arguments, allowing you or your lawyer to plead your case.
- The Reviewing Board can send the case back to the administrative judge for further findings of fact. This is done when it is felt there is insufficient evidence.
- The Reviewing Board may affirm the original decision without discussion of the issues.
Which option the Reviewing Board chooses will depend on how strong the evidence you have submitted is.
Denied Surgery
Some workplace injuries may require additional surgery to rectify. This should be covered by workers’ compensation, but it can be denied. There are multiple reasons surgery may be denied, such as the surgery is deemed unnecessary, the injury was not work related, or it is believed you did not follow the doctor’s orders after the initial injury. Luckily, if you are experiencing workers’ comp denied surgery, you can appeal the decision in an attempt to have the surgery covered.
What Happens to Medical Bills When Workers’ Comp Is Denied?
Unfortunately, if your claim is denied, workers’ comp insurance will not cover any of your medical bills. This means that you will be personally responsible for paying any and all medical bills. If you have it, you may be able to use personal health insurance to cover your medical bills. However, if you don’t have a personal policy or your policy does not cover your medical bills, you will have to pay for all medical costs out of pocket.
When to Contact a Workers’ Compensation Lawyer
As soon as your claim is denied or disputed, you should hire a workers’ compensation lawyer. You should also contact a lawyer if you have any doubts at all regarding the level of compensation you’ve been offered, how quickly you’ve been cleared to return to work, or how long-lasting your injury will be. A workplace injury can have life-altering consequences, and thus should be taken seriously. It is always wise to engage legal counsel to ensure you receive the compensation you deserve.
Disclaimer
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