Why are Some Workers’ Compensation Claims Denied?

When employees are injured in a workplace accident, they expect that their employer will protect the employee’s right to receive workers’ compensation benefits. Unfortunately, that does not always happen. Watching the bills pile up for a work injury when employees are unable to bring home a paycheck, and then learning that their workers’ compensation claim has been denied, can be extremely stressful.

In one survey, 47 percent of employees who received workers’ compensation benefits initially had their claim denied. With the right guidance and advocacy, a denied claim can be reversed. Our qualified legal team at Pietras Saracino Smith & Meeks, LLP can help injured employees appeal a denial and recover the financial compensation that they deserve.

How are Workers’ Compensation Claims Processed?

Workers’ compensation claims are processed after the employee reports the injury to an immediate supervisor. The supervisor is supposed to initiate an insurance claim through their office or the insurance department for the company. Because employers are required to carry workers’ compensation insurance for most employees, filing a claim should be straightforward.

The claim will be handled by the insurance company, who will absorb all the liability that the employer would have had without carrying insurance. This means that the focus is squarely on the insurance company. The insurance company should pay for lost wages that are covered under workers’ compensation, as well as medical care and rehabilitation.

If this does not occur, we ask that our clients reach out to us as soon as possible for help. Because we have experience in the industry, we know how to pinpoint issues with each claim that can be resolved. We do not stop fighting for the rights of our clients until we have exhausted all our options. We have enough experience in the field to know which methods are most effective when attempting to recover compensation.

What Should Injured Workers Do After an Accident?

When workers are injured, they should use the following steps to handle the accident as efficiently and safely as possible. We know that some workers need help from others. Therefore, it is important for all workers in New Jersey to know what to do when an accident occurs because alert workers can help their injured colleagues. The following tips should be used to respond to an accident properly:

Call 911 immediately. Calling 911 helps the injured employee receive immediate medical attention. If the injury does not rise to this level, the employee needs to be sent home so that they can go to the doctor. Because the company is supposed to carry workers’ compensation insurance, the company also has a list of approved doctors that the injured employee can see that day.

Report the injury. The worker should report the injury when it occurs, or they should come back to work to report their injury. The supervisor should be asked how the company wants the injury to be reported, and these protocols should be followed to avoid any delays.

Obtain and keep receipts for medical care. Employees who are receiving medical care under the presumed coverage of a workers’ compensation plan need to collect their receipts. These receipts can be used when the insurance company does not pay, and a claim must be filed for compensation.

Take pictures of the accident scene. Pictures of the accident scene are necessary when filing a claim for coverage.

Provide timecards and logs. Timecards and logs will show that the employee was at work and doing their job. We can collect testimony from colleagues who were present and build a compelling case for coverage.

When an injury occurs at work, these steps can help prevent denials. We can rebuttal many of the claims that an insurance company or employer might make when denying workers’ compensation, but we need the evidence that can be collected using the steps listed above. It is important to remember that the state of New Jersey has a two-year statute of limitations for all workers’ compensation claims. A worker also has two years from the date of their last receipt of benefits if their coverage has been cut off.

Common Reasons a Workers’ Compensation Claim May Be Denied

Workers’ compensation claims are denied for a variety of reasons. It is normal for employees to assume that they will be covered when they file a claim correctly. However, the employee needs to know what might cause a denial. We will review the case and determine why a denial might have occurred. We can help employees correct a simple error, or we will fight for our client’s right to coverage based on the evidence we have gathered. Denials occur because of the following reasons:

The injured employee did not seek medical treatment for their injury right away. When workers do not seek immediate medical care, it looks suspicious to an insurance company or employer. The seriousness of the injury may be questioned. We ask that our clients always go to the doctor or call 911. If there was an obstacle that prevented medical treatment, we ask our clients to tell us what happened. We can explain to the insurance company or employer why medical assistance was not sought immediately after the accident. We also recommend that workers go to the doctor for even minor injuries; these injuries could worsen if they are not treated.

The injured employee did not report the injury or submit the claim within the required window of time. When the injury has not been reported within two years of the date the accident occurred, the employer cannot submit an insurance claim. Some people have moved on from the jobs where they were hurt, and there might not be any evidence. Clients should reach out to us when it seems difficult to file a claim with a supervisor or the employer.

The employee did not provide all requested information by the deadline. Injured employees may be asked to submit extra documentation for the claim, and the insurance company will say that the employee has not been cooperative. Some of these cases are simple misunderstandings, and we can help mitigate these concerns. We can also submit information to the insurance company that may have been rejected in the past.

The employee has a pre-existing condition. The insurance company may claim that the injury is the result of a pre-existing condition.

The injury occurred away from the worksite or outside of the employee’s normal work hours. Injuries might occur away from the worksite or business, but not all off-site injuries will be denied. If the worker is driving from one location to another or visiting a site as part of their job duties, their injuries are still compensable.

The employee is accused of inappropriate behavior or substance abuse. We work with clients who have been denied because the insurance company or employer claimed inappropriate behavior or substance abuse might have been involved in the accident. We will take statements from witnesses who were present on the day of the accident, and we can even collect photos or videos from the accident scene that show our client was doing their job.

Are There Situations That Workers Should Avoid?

Injured employees may be upset by a denied workers’ compensation claim. This is to be expected because the worker needs to support their family, pay their bills, and live their life as normally as possible. We always ask our clients to be careful when handling a denied workers’ compensation claim because certain actions can make it even more difficult for us to recover compensation. Workers should avoid the following situations in the wake of a denied claim:

Complaining to their employer. When our clients have been injured at work, we know that it can be distressing to have a workers’ compensation claim be denied. Clients who call their employers to complain are misplacing their anger. The employer often has no control over whether the claim is denied. The claim was sent to the insurance company, and a supervisor or even the company owner simply does not have that much control over the process.

Complaining to the insurance company. This is not advised because the insurance company records calls. These companies are in the business of making money, and they will look for any way to pay as little as possible. If the client complains to the insurance company, makes threats, or uses profanity, the insurance company will bring up these conversations when legal action is taken. Although this behavior has nothing to do with the accident, the insurance company will do anything possible to deny compensation

Filing a complaint with the state. Filing a complaint with the state will not help, especially when it appears that the insurance company, employer, and everyone else involved in the claim followed procedure. The state will quickly kick back the complaint because our clients cannot collect the evidence necessary.

Complaining to the assigned doctor. When a workers’ compensation claim is filed, the worker is assigned to a doctor. The doctor might have been authorized to provide a certain level of care. Therefore, they might discontinue care or authorize the employee to go back to work. Injured workers should not complain to the doctor or file a complaint against the doctor’s license. If the doctor is acting inappropriately, we will uncover their misconduct.

Speaking to a lawyer who wants to settle quickly. Lawyers might contact the injured employee to offer a settlement to close the case quickly. This often happens when an employee cannot go back to work again. The insurance company might offer to pay a lump sum settlement to close the case, but that settlement is not nearly as valuable as all the medical and lost wage payments that should be provided under state law.

What Should Be Done When a Claim is Denied?

When employees are denied workers’ compensation benefits, they need to know the reason. The employee should receive a letter from the employer or the insurance company that explains the reason for the denial. The employee should bring that letter to our offices for review, and we will look at what needs to be done to reverse the denial. In some cases, we can correct a misunderstanding or a filing error that may have occurred.

Managers and supervisors might have filed the claim improperly, and we will show that the employee did not cause this problem. Employees might have forgotten to file the claim, and we can help submit that report. Employees should also not feel dejected when they are denied workers’ compensation. We can direct our clients to a doctor who can help provide a diagnosis, or we can confer with medical experts who will show that the injury clearly occurred at work.

Additionally, we will handle all communication in the case. We can talk to the stakeholders at the insurance company or managers who might have been involved. Although we cannot sue the employer, we want to know if a particular manager or supervisor might have been mistaken, filed the claim improperly, or acted on incorrect information.

Why Hire an Experienced Workers’ Compensation Lawyer?

Seeking an appeal can be complicated, especially when injured workers thought that they had a legitimate claim and all the steps were properly completed in the first place. We can help injured workers and their families thoroughly review the application to see what went wrong, correct any paperwork mistakes, gather appropriate documentation, and file a strong appeal.

Our lawyers have more than 140 years of combined experience helping injured workers receive the benefits they are entitled. We understand the challenges injured employees and their families may face, and the steps needed to recover the benefits that workers deserve. Our firm has been recognized as a premier workers’ compensation law firm since 2003. Any case we take on is handled by an attorney with a minimum of 10 years of experience handling workers’ compensation cases.

If a workers’ compensation claim has been denied, the employee needs to take immediate action. They should not do it alone. We can help injured employees or their families recover the maximum award for their medical costs, medications, and other health care-related expenses, along with a portion of the wages that were lost while the employee was out of work during their recovery.

Can a Denied Workers’ Compensation Claim Be Appealed?

A denied workers’ compensation claim can be taken into the court system and appealed if necessary. We hope that our clients can agree to a settlement or receive the care that they need. However, we are willing to go to court when required. Our clients should not attempt to represent themselves in court. The insurance company will have a staff of lawyers ready to protect its interests, and our lawyers will appeal any decisions made by the insurance carrier.

When a claim has been denied, we can take that case to the Appellate Court of the State of New Jersey. The case will be heard by a judge, and we will frame a compelling case that shows our clients should have been covered. These cases cannot go any further according to state law, but we are willing to fight in court if the insurance company is not willing to pay out the proper benefits.

How are Damages Assessed When Filing a Claim?

When damages are assessed as part of a workers’ compensation lawsuit, the insurance company could be held liable for a range of costs. Initially, the insurance company should pay the following:

  • Medical costs
  • 70 percent of the worker’s weekly salary
  • Vocational rehabilitation
  • Death benefits when the worker dies in the accident or as a result of their injuries

If an insurance company challenges a workers’ compensation claim, it will not pay for medical costs, wage loss, or vocational rehabilitation. When we file our claim, we will request the following compensation:

  • Legal costs
  • Unpaid medical bills
  • Unpaid wage-loss benefits
  • Unpaid rehabilitation costs

We simply want to recover payments that the injured worker should have received. When we go to court, we can calculate what the insurance company must pay, and we will request a judgement for the full amount. We know that living with a serious injury, being unable to pay medical bills, and not having an income can be traumatic for the worker and their family.

We will fight tirelessly to recover the funds that our clients deserve and ensure that our clients understand the legal process. We can prepare our clients to testify in court, and we will speak on behalf of our client. We will also request death benefits if a family lost a loved one to a work injury. Death benefits pay for final expenses and burial costs. If the case rises to that level, we will petition for death benefits that should have been paid when the worker died.

South Jersey Workers’ Compensation Lawyers at Pietras Saracino Smith & Meeks, LLP Help Injured Workers Reverse Denied Claims

If you were injured on the job, talk to one of the South Jersey workers’ compensation lawyers at Pietras Saracino Smith & Meeks, LLP to discuss your options. Call us today at 856-761-3773 or contact us online to schedule a free consultation. Located in Cherry Hill, New Jersey, we serve clients throughout South Jersey, including Camden, Cinnaminson, Delran, Maple Shade, and Pennsauken.

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