If you receive a workers’ compensation claim denial, you may still qualify for benefits. Review the letter to find out the reasons behind the denial. If you feel the denial is unjustified, you have the ability to appeal and present evidence supporting your case. A lawyer in Naperville can improve your chances of a successful appeal, so consult with one as soon as possible. Deadlines are important, so stay proactive throughout the process.
Workers’ compensation offers financial support to many injured workers and their families. You may still have options with a denied workers’ comp claim, so call Chute, O’Malley, Knobloch, and Turcy at 630-412-4747 to discuss your case.
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Understanding Your Workers’ Compensation Claim Denial
Workers compensation claims can get denied for reasons such as missed deadlines or insufficient medical evidence. Understanding the reason(s) behind your denial can help your appeal.
Missed Deadlines
Illinois requires that injured workers report their injury or illness to their employer within 45 days, either orally or in writing. If you miss this deadline or other important deadlines, you risk workers’ compensation claim denial.
A missed deadline does hurt your chances of a successful appeal, but consulting with workers’ compensation lawyers about your situation will clarify if you could still get benefits. The circumstances of your situation might allow for leniency.
For instance, if you missed the deadline because you were incapacitated, an extension might be possible. Meanwhile, if your employer knew about your injury, your claim could have a chance even if you did not follow the strict steps and timelines required.
Similarly, if your employer or insurance company misrepresented the situation or acted fraudulently, a deadline extension might be possible. Among the top workers’ compensation tips is to contact insurance carriers yourself (or have your lawyer do so) if your employer is not performing the notification of your injury.
Insufficient Medical Evidence
Workers’ compensation claims need enough medical evidence linking the injury or illness to the job. Insufficient medical evidence could occur in the following situations:
- Inadequate examination: The medical provider might have been unfamiliar with workers’ compensation claim requirements or rushed the examination, resulting in subpar documentation. In some situations, a specialist examination is necessary.
- Conflicting medical opinions: When medical opinions conflict, it is often due to the employer’s doctor saying the injury is less serious than it seems, while the worker’s doctor views the injury as serious.
- Treatment delays: A delay between the injury and medical treatment could create an opportunity for others to argue that the injury occurred outside of work.
- Pre-existing conditions: A doctor may claim that your injury is from a pre-existing condition rather than a work-related injury.
- Inadequate follow-up: Follow-up is necessary to document the progression or improvement of an injury and the effect of treatment. When injured workers fail to show up for appointments or follow their treatments, they hurt their case.
Unfortunately, a workers’ compensation claim denial is all but inevitable if one of the above situations apply. The good news is that appealing can remedy the issue.
It is also important to note that some injuries or illnesses occur gradually. Carpal tunnel is an example, and knowledgeable medical professionals are necessary to show that it is work-related.
Deadlines can get tricky with a situation such as this, too. For repetitive strain injuries, the deadline clock starts from the date the employee becomes aware, or reasonably should have been aware, that his or her condition is work-related. Often, this happens when a doctor diagnoses an employee.
Injury Circumstances
Disputed circumstances of the injury can lead to a workers’ comp claim denied. Employers or insurance companies might say that pre-existing conditions caused an injury. Alternatively, they might say it did not happen at work.
Employment Status
Workers’ compensation insurance in Illinois covers about 91% of employees in the state. People who can exempt themselves include sole proprietors and business partners.
Independent contractors are among the people typically not covered by workers’ compensation. Your lawyer can help clarify your employment status based on the level of control the employer has over the work. You might be an employee if the employer directs your work, supervises you, sets your work schedule, provides your tools and equipment, and is your primary or sole work source. There are many other ways to show employee vs. independent contractor status, such as being paid regular wages rather than per project.
Steps to Take After a Denial
You can take several steps after a denied workers’ comp claim to pursue your benefits.
1. Review the Denial Letter
The workers’ compensation claim denial letter should detail reasons for the denial, including pieces of information or documents that are missing.
2. Collect Needed Evidence
Many claims are denied due to insufficient medical evidence. If this is your situation, work on gathering necessary evidence. For instance, you can reach out to your medical providers for clear documentation of the link between your work and injury. Medical experts may be able to explain the link, too.
If the denial is due to disputed injury circumstances, you could get witness statements from co-workers or others who saw what happened, where, and when.
3. Correct Mistakes
If errors or missing information led to your claim being denied, fix these issues as soon as possible.
4. Discuss Your Situation With an Attorney
Talk with a workers’ compensation attorney about your denial and how you might still get benefits. An attorney can help with gathering the evidence and navigating the appeal. These attorneys usually offer free consultations and work on a contingency fee basis, so you do not need to worry about making large upfront payments. Attorneys get paid based on a percentage of the benefits they get you.
Choosing the best workers’ compensation lawyer can make a difference in your case. Work with someone who has deep experience in workers’ compensation and how well the attorney communicates the issues to you and answers your questions. Ask about his or her history in successfully appealing denied workers’ compensation claims.
5. File an Appeal
Appealing a workers’ compensation claim denial involves several steps and deadlines. Be as proactive as possible so you do not miss deadlines.
How to Navigate the Workers’ Compensation Appeal Process in Naperville, Illinois
Appealing your claims denial involves several stages, and navigating the process also involves paying your bills while waiting on workers’ compensation. An attorney may expedite your claim and connect you to financial resources.
1. File the Appeal
You have 30 days from the date you got the workers’ compensation claim denial letter to file your appeal with the Illinois Workers’ Compensation Commission. Set up a lawyer consultation as quickly as possible after getting your denial letter. Your lawyer can identify the strengths and weaknesses in your case, and devise a strategy for the appeal.
When the commission gets your appeal, it assigns the case to an arbitrator and schedules a hearing.
2. Consider Settlement
The insurance company has the ability to settle your case before or after the hearing. A lawyer can help make sure that any settlement offers you accept are fair.
3. Present Your Case
At the hearing, be prepared to testify about the reasons your claim was denied. For instance, if insufficient medical evidence is the reason, you may need to testify about your injuries, the treatment you received, and how the injury affects your ability to work. Use medical records, opinions from medical experts, testimony from co-workers or witnesses, and other helpful documents to prove your case.
4. Explore Further Options
Many appeals in the Naperville area succeed, but some do not. Arbitrators sometimes uphold a workers’ compensation claims denial. The options available at this stage commonly include further review by the Illinois Workers’ Compensation Commission or filing a lawsuit in civil court. With a review, three commissioners go over your case, and you might be able to use additional arguments.
If you still encounter roadblocks, it is possible to appeal to higher courts. Each stage requires deadlines and procedures.
5. Follow Top Tips for a Successful Appeal
Keeping these tips in mind can be helpful for your workers’ compensation claim denial appeal.
- Be proactive: Missing just one deadline can mean your appeal gets dismissed.
- Be thorough: Focus on collecting comprehensive, well-documented evidence. It is better to have too much than too little. Your lawyer should know what types of evidence to present and when.
- Stay organized: Set up a physical and electronic file to store records of all communications, documents, and evidence to do with your case.
Suffering a work injury or illness is stressful enough. Dealing with the denial of your workers’ compensation claim adds even more frustration, but you don’t have to navigate the process alone. Contact us at Chute, O’Malley, Knobloch, and Turcy to talk about your case.