How Do I Fight a Denied Workers' Compensation Claim?

How Do I Fight a Denied Workers' Compensation Claim?

Workplace injuries should be covered by your employer’s workers’ compensation insurance, but it still is possible your claim may be denied. If your claim has been denied, don’t lose hope. You still have some options. Keep reading to learn more about why your claim may have been denied, and what you can do about it.

Why Do Workers’ Compensation Claims Get Denied?

If your claim was denied, the first thing you will need to know is why. The reason should be explained in the denial letter. If your denial was reached in error, you could be eligible for an appeal. Common reasons workers’ compensation claims are denied may include:

  • The injury wasn’t reported in a timely manner. Many states have laws that dictate how long an employee has until the must notify their employer of their injury. This period is typically only a few days.
  • The claim was not filed in time. State laws also determine the amount of time you have to file your claim. This period is typically 30 to 90 days from the date of the accident that injured you.
  • Your employer disputed the claim. Your employer may dispute your claim in order to avoid having to pay the insurance premium increases. They may claim your injury occurred due to a disqualifying reason, such as horseplay, being intoxicated at work, or that the injury occurred outside of work.
  • The injury isn’t compensable. Claims for stress-related injuries can be difficult to file a claim for in many states. It is possible that emotional injuries, suicide, and self-harm caused by work-related stress will not be covered by workers’ compensation.
  • No medical treatment. For your claim to be considered, you will need to have sought and completed some form of medical treatment for your injuries.
  • Insufficient evidence that the injury is work-related. It sometimes can be unclear whether an injury is work-related or not. Additional medical examinations may be necessary.

Appealing a Workers’ Compensation Claim

Now that you better understand why your claim was denied, you may decide to appeal the decision. In the denial letter, you should find a deadline for filing your appeal. This deadline is determined by state law. If you plan to file an appeal, this is an important date to keep in mind as you move forward.

You may choose to start by contacting your employer or their insurance company to determine if the dispute is easily resolved. It is possible that there is a simple clerical error or misunderstanding to blame for the issue. If not, you can move on to your actual appeal.

Appeals are complex legal processes, so it is important to speak with an experienced workers’ compensation attorney. Your lawyer can guide you through every step of the appeals process and ensure no detail is overlooked that may help your case. The appeals process can vary from state to state, but in South Carolina the appeals process typically involves:

  • An appeal hearing before a Commissioner.
  • A Commission-ordered medical examination
  • A Commission review with a board of three Commissioners

Hearing Request

The first step in your appeals process is to submit a hearing request to the South Carolina Workers’ Compensation Commission, along with the $25 filing fee. At this hearing, you will be heard by one Commissioner. Upon requesting the hearing, the Commission will schedule a hearing with you, typically in the county where you were injured.

In some cases, you may be required to undergo a medical examination by a Commission-selected physician. The doctor will examine you and testify at the hearing about your medical condition. You will also be allowed to testify and present your case.

After the hearing, the Commission will issue an “order,” or decision on the matter. If they decide against you, you still may appeal the order.

Commission Review

If the first Commissioner’s order was not in your favor, you can appeal one more time. A Commission review must be requested within 14 days of receiving the order from your first hearing. You will be required to also submit a filing fee of $150, or a Request to Waive Appeal Filing Fee if you are unable to afford the fee.

At a Commission review, a panel of three Commissioners will hear your case and consider it. They will issue a decision that is known as an “award.” An award notification will be sent to you, in addition to the legal rulings and the “findings of fact,” or Commission statement about what the Commissioners believe to be the facts of your individual case.

If the Commission review finds your appeal to be “without merit,” you could be subject to a $250 fine. This means the Commission found that you have no grounds upon which to disagree with the initial hearing’s order and there was no reasonable basis on which the Commission could alter the order. Generally, this is reserved for extreme or fraudulent cases.

Still Have Questions? Ask Our Charleston Workers’ Compensation Attorney – (843) 968-0886

Since 1999, our team at Pierce, Herns, Sloan & Wilson, LLC has been dedicated to helping injured workers receive their rightful compensation. Our highly skilled and knowledgeable Charleston workers’ compensation lawyers know the complexities of the system and can guide you safely through it. Don’t hesitate to get help with your claim.

Schedule a free consultation today! Contact our team by calling (843) 968-0886.

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