So you got injured at work. You file an OWCP workers comp claim and hope to receive compensation for your lost wages and medical expenses. And then it happens. You get your paperwork back with a big ‘denied’ stamp in the middle.
Fortunately, a rejected workers comp claim is not necessarily the end of your journey. You have the option to appeal your denial and receive compensation. But you must follow the correct process.
What are the Common Reasons for Rejected a Workers Comp Claim?
Insufficient Evidence
Workers must provide evidence that shows their injury was work-related. Insurance companies want to pay out as little as possible. Therefore, you must present an airtight case that proves your injury was caused by work activities.
If the insurance company is not convinced by your workers comp claim, they may ask for additional evidence, such as:
- Police report that detail what happened when the injury occurred
- Photographs that show the injury and how it occurred
- Medical documents that verify the extent of the injury and how it occurred
- Statements from witnesses who saw the injury occur
- Employer affidavits that acknowledge what happened
Workers often pay out of pocket to get the evidence they require. They will be reimbursed if their workers comp claim is approved. But approval is not guaranteed.
Procedural and Application Errors
A workers comp claim must be filed by the book. If the employee fails to follow the correct procedure, files too late, or does not provide the required evidence, the claim will be denied. Common application and procedural errors include:
- Not submitting the required documentation
- Leaving sections blank on required forms
- Providing inaccurate contact information
- Providing incorrect dates and locations
Some of these errors can be corrected, but the process will extend the case. An investigation will be necessary. Meanwhile, the worker may hemorrhage money due to lost wages and medical bills.
Failure to Seek Medical Attention
A workers comp claim requires medical documentation that proves the extent of the injury and shows that it was work-related. Medical care must be obtained within a timeline that varies depending on the nature of the injury. If the employee fails to get medical attention, the claim will be denied.
In some cases, the board may decide that your medical evidence is not compelling enough. Lack of strong medical evidence can weaken your case and negatively affect the outcome.
Witness Credibility
Witness credibility is often a factor in workers’ comp claim denials. Witnesses may be cross-examined. If their statements are inconsistent, they may kill your claim.
Pre-Existing Conditions
A pre-existing condition will make it difficult for doctors to determine if your injury was work-related or caused by a past injury. The claims administrator may argue that the condition caused your disability. These circumstances can hurt your workers comp claim.
Disputes Over Disability Ratings
Workers receive disability ratings that indicate the extent of the injury. They are a deciding factor in how much compensation you receive. If workers disagree with their disability ratings, they must bring in additional medical evidence to support their case.
What To Do If a Workers Comp Claim is Rejected
File an Appeal
Workers can file an appeal for rejected claims. There are various ways to file an appeal as follows.
Appeal to the Employees’ Compensation Appeals Board (ECAB): The ECAB hears appeals and awards under the Federal Employee’s Compensation Act. The board decides on appeal Office of Workers’ Compensation Programs cases impartially. Their decisions are based on case reviews and follow statutory mandates. Injured workers have the right to a full hearing with the OWCP’s Branch of Hearings and Review before the board review.
Appeal to the Branch of Hearings and Review: The claimant who files an appeal is entitled to a hearing before an Office representative. They may receive a review of the written record that can be submitted as evidence. The hearing will consider issues addressed in the contested decision.
Reconsideration Carried Out by the District Office: Workers may file their appeal locally through their district office. The appeal must be submitted within a year of receiving the denial. It will be handled by the same office that rejected the original workers comp claim. It must be submitted with new evidence that states why your injuries require compensation.
Do I Need a Lawyer for My Workers Comp Appeal?
A lawyer is not necessary for a workers’ comp appeal. However, some people choose to hire legal assistance during the appeals process.
A lawyer may help you determine why your claim was rejected. They will help you gather the necessary evidence to ensure your claim is accepted. They may also help expedite the process.
Most workers’ comp lawyers work on a contingency fee basis. In other words, they will only get paid if they help you win your case. Their fee will be a percentage of the benefits you receive.
What Can I Do If My Appeal Is Denied?
Workers have options even after an appeal is denied. The process varies by state. In California, you can obtain a writ review or appeal to the California Supreme Court. In New York, you can appeal the decision with the New York State Court.
Research to determine the options available in your state. Note, that you must file a second appeal within a specific amount of time.
Final Thoughts
No one likes to see the word ‘denied’ stamped across their workers’ comp claims. Fortunately, you can appeal your denial through the ECAB or your district office. You can even apply for a second appeal. Good luck getting the compensation you require.