There are various reasons why your employer’s worker’s comp carrier may contest your claim for benefits. If you filed your claim after the deadline or failed to provide the required notice, your claim could be contested. There may also be issues related to your injury, how and when it occurred, which may result in a dispute. Ultimately, claims contested by the Worker’s Comp Carrier will need to be appealed.
Common reasons your claim may be contested
Probably the most common reason workers’ comp claims are contested or denied is the failure to file the claim or report it to the employer before the deadline has passed. Worker’s comp law requires injured employee’s to report the claim immediately, sometimes within a matter of days. Also, employers and insurance carriers frequently contest claims that they believe are not work-related, including injuries or illnesses that they argue are preexisting. Depending on your state, there may be certain medical conditions that are not covered. Ultimately, you will be notified in writing as to the reason your claim has been contested.
The Workers’ Compensation Appeals Process
The Worker’s Compensation insurance system is based on administrative law, which means an administrative agency, as opposed to a court of law, will oversee the entire system, including any claim contest or appeal. Administrative law judges are responsible for conducting hearings, which are very similar to civil trials. If your claim is contested by the worker’s comp carrier, then your next step is to seek an appeal.
Asking for reconsideration of the decision
The steps in the Worker’s Compensation Appeals process may be somewhat different, depending on the state you work in, but here are the basic steps that everyone must take in order to appeal a decision denying worker’s comp benefits. The first step is to determine why your claim was contested or denied. If you are lucky, the matter may be resolved quickly. If you failed to submit a required document or any necessary evidence, you may be able to remedy the problem by simply supplying the required information. Once you do that, the worker’s comp carrier can reconsider your claim.
Requesting a formal appeal may be necessary
If those steps do not resolve the problem, it may be necessary to file a formal appeal, pursuant to the guidelines established by your state workers’ comp agency. Typically, the written notice of denial that you received will describe the specific steps you need to take to begin the appeal process. Be sure you read the letter carefully and make note of all appeal deadlines.
What does the administrative law judge need to consider?
At the appeal hearing, it will be necessary to present medical evidence and other factual support for your workers’ compensation claim. This includes any evidence required to establish that your claim is for a work-related injury or occupational disease. Usually, the review of a worker’s compensation decision is limited to questions of law, meaning that the facts will be assumed correct and only the legal issues will be examined for errors. This would include the character and credibility of the witnesses and any other rulings on the evidence.
If you have questions regarding contested claims, or any other workers’ compensation issues, call the Cottrell Law Office at (800) 364-8305.
He is licensed to practice law in the United States District Court for the District of Kansas, eastern Arkansas, western Arkansas, and western Missouri. He was Deputy Prosecuting Attorney in Crawford County, Kansas from 1987-1989.
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