Stephen Hasner | Workers' Compensation | October 7, 2024
Individuals who suffer an injury or illness while on the job and working within the scope of their employment may be eligible to file a workers’ compensation claim. However, in some cases, the State Board of Workers’ Compensation may deny the claim for various reasons.
If your claim for workers’ compensation benefits has been denied, you need an experienced attorney advocating for you as soon as possible. Your lawyer can appeal the claim denial and pursue the benefits you need for your workplace injury or illness.
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Common Medical Conditions Suffered While on the Job
Many workers face serious risks on the job, and injuries or illnesses can occur in almost any work environment. These injuries and illnesses can lead to workers’ compensation claims, which help cover medical expenses, lost income, and rehabilitation. Here are some of the most common types of workplace injuries and illnesses that employees may experience.
One of the most frequent workplace injuries is strains and sprains, which occur when muscles or ligaments are overstretched or torn. Lifting heavy objects, repetitive motions, or poor posture can all lead to these types of injuries. Workers who perform physical labor, such as construction workers or warehouse employees, are especially at risk.
Back injuries are also common, especially in jobs that require heavy lifting or bending. These injuries can range from minor muscle strains to serious spinal damage. Jobs that involve a lot of physical activity, like nursing or factory work, are more likely to cause back problems.
RSIs occur when a worker repeatedly performs the same motion, such as typing, using machinery, or assembling products. Carpal tunnel syndrome is one of the most well-known RSIs. Over time, this type of injury can cause severe pain and limit movement.
Moreover, workers in almost any industry can experience a fall or slip injury. Slips can happen on wet floors, icy sidewalks, or uneven ground. Falls from heights, such as ladders or scaffolding, are more common in construction but can happen in offices as well. These accidents can lead to broken bones, concussions, and other serious injuries.
Workers exposed to loud machinery, such as in manufacturing or construction, are at risk for hearing loss. Over time, exposure to high noise levels can lead to permanent damage, even if hearing protection is worn.
In industries like mining or construction, workers may breathe in harmful chemicals, dust, or fumes, leading to respiratory illnesses. Long-term exposure can cause serious conditions like asthma or lung disease.
Workers who handle machinery, chemicals, or hot substances are at risk for burns and cuts. These injuries are common in industries like food service, manufacturing, and construction.
If any of these injuries or illnesses occur, workers can often file a claim for workers’ compensation benefits to help recover from their losses.
Process of Filing a Workers’ Compensation Claim
Employees who suffer injuries or illnesses while performing their job duties can qualify for workers’ compensation benefits. However, not everyone can file a claim, and there is a specific process that must be followed. Here’s a general overview of who can file a workers’ compensation claim, the steps involved, and how a lawyer can help.
Who Can File a Workers’ Compensation Claim?
To file a workers’ compensation claim, a person must be classified as an employee. This includes full-time, part-time, and temporary workers in most industries.
Independent contractors, freelancers, and volunteers typically do not qualify for workers’ compensation benefits, though exceptions may apply in certain situations. Additionally, only a work-related injury or illness will qualify. This means it occurred while performing job duties or as a direct result of the work environment.
The Process of Filing a Workers’ Compensation Claim
The process for filing a workers’ compensation claim generally follows these steps:
- Report the Injury—The first and most important step is to report the injury or illness to your employer as soon as possible. Most states have strict reporting deadlines, ranging from a few days to a few weeks after the incident. Failing to report the injury within this timeframe can jeopardize the claim.
- Seek Medical Attention – After reporting the injury, the employee should seek medical care right away. In many cases, the employer or the workers’ compensation insurance provider will require the worker to visit a specific doctor or facility.
- Complete a Claim Form – The employee must fill out a workers’ compensation claim form, usually from the employer or their insurance company. This form includes details about the injury and how it happened.
- Submit the Claim – Once the claim form is completed, it will be submitted to the employer or the insurance company. From there, the workers’ compensation insurance provider will review the claim and determine whether to approve or deny it.
How Can a Lawyer Help?
A lawyer experienced in workers’ compensation law can be invaluable throughout this process.
They can fill out all necessary paperwork correctly and on time. The lawyer can appeal a denial and represent the worker during hearings or negotiations. Additionally, a lawyer can explain the worker’s rights and ensure that they are treated fairly throughout the claims process.
Possible Workers’ Compensation Benefits
Workers’ compensation can support employees who suffered an injury or become ill due to their job. The injured worker may qualify for several benefits. These benefits cover medical costs, lost income, and any permanent effect on the worker’s ability to earn a living.
Below are the most common benefits that an injured worker may receive as part of a workers’ compensation claim.
- Medical Benefits – Medical benefits cover the cost of medical treatment needed to recover from a work-related injury or illness. This can include doctor’s visits, hospital stays, surgery, physical therapy, medications, and any necessary medical equipment, like crutches or wheelchairs. Workers’ compensation also typically covers rehabilitation services, which help the worker regain their physical abilities and return to work as soon as possible. In some cases, it may also cover psychological treatment if the injury or illness leads to mental health issues.
- Temporary Disability Benefits – Temporary disability benefits can support an injured worker who cannot work for a certain period of time but might recover and return to their job. These benefits replace a portion of the worker’s lost earnings during their recovery. The amount typically equals a percentage of the worker’s average weekly earnings before the injury occurred, though the exact percentage can vary by state. Workers’ comp usually limits how long an employee can receive temporary disability benefits.
- Permanent Disability Benefits – If the worker’s injury or illness results in a permanent condition that prevents them from returning to work in the same capacity, they may be entitled to permanent disability benefits. These benefits compensate for the loss of earning potential. A worker can suffer partial permanent disabilities, where the worker can still do some form of work, or total, which completely prevents them from working.
- Vocational Rehabilitation Benefits – Vocational rehabilitation benefits help injured workers who cannot return to their previous job due to their injury. These benefits may cover the costs of retraining, education, or job placement services. They help the worker develop new skills so they can find employment in a different field that accommodates their limitations.
- Death Benefits – In tragic cases where a worker dies due to a work-related injury or illness, workers’ compensation may provide death benefits to the worker’s dependents. These benefits typically include compensation to cover funeral expenses and financial support for the deceased worker’s spouse, children, or other dependents.
Each state has specific rules and guidelines for workers’ compensation, so the exact benefits an injured worker may receive can vary based on location.
Reasons Why Workers’ Compensation May Deny a Claim
Workers’ compensation can deny claims for several reasons, often due to issues with eligibility, documentation, or injury circumstances.
Below are some common reasons why workers’ compensation may deny a claim.
- Failure to Report the Injury on Time – Most states require workers to report a workplace injury or illness to their employer within a specific timeframe – often within a few days or weeks of the incident. If an employee fails to report their injury within the required time, the employer or the workers’ compensation insurance company may deny the claim. Delayed reporting can raise doubts about whether the injury is work-related or how serious it is.
- Injury Not Work-Related – For a workers’ compensation claim to be approved, the injury or illness must be directly related to the worker’s job. Claims may be denied if there is evidence that the injury occurred outside of work or while the employee was engaged in activities unrelated to their job duties. For example, if an employee suffers an injury while on a break off company property, the injury may not qualify for workers’ compensation.
- Lack of Medical Evidence – If insufficient medical documentation supports the claim, the insurance company may issue a denial. Workers need to provide evidence that their injury or illness is real and that it is related to their job. This typically requires a diagnosis from a medical professional and medical records that outline the treatment plan. Without clear medical evidence, workers’ comp may deny the claim.
- Pre-Existing Condition – Claims may be denied if the insurance company believes that the injury or illness is the result of a pre-existing condition rather than a work-related incident. If an employee had a prior injury or condition, the insurance company may argue that the new injury is just an aggravation of the old one and not eligible for compensation.
- Employee Misconduct – If the injury occurred while the employee was violating company policies, acting recklessly, or under the influence of drugs or alcohol, workers’ compensation may deny the claim. Insurance companies may argue that the injury resulted from the worker’s misconduct rather than normal job-related duties, making it ineligible for benefits.
Steps of Appealing a Workers’ Compensation Claim Denial
If workers’ compensation denies a claim, it can frustrate and confuse the injured worker. However, you must take specific steps to appeal the denial. A lawyer can make navigating this process significantly easier.
Here’s a breakdown of the various steps involved in appealing a workers’ compensation claim denial and how a lawyer can help you.
- Review the Denial Letter – The first step in the appeals process is to carefully review the denial letter from the insurance company. This letter typically outlines the reasons for the denial, which may include lack of medical evidence, missed deadlines, or claims of the injury not being work-related. You need a lawyer who understands the specific reasons for the denial, as it will guide your next steps.
- Gather Documentation – Once you know the reasons for the denial, you should gather all relevant documentation to support your case. This may include medical records, accident reports, witness statements, and any correspondence with your employer or the insurance company. A comprehensive collection of evidence can strengthen your appeal.
- Consult a Lawyer – Engaging a lawyer who regularly handles workers’ compensation cases can provide you with invaluable guidance. A lawyer can assess your situation, clarify your rights, and determine the best course of action based on the specific details of your case. They can also explain the appeals process and what documentation can support your claim.
- File an Appeal – Depending on your state’s regulations, you may need to file a formal appeal with the workers’ compensation board or agency. This usually involves completing specific forms and submitting them along with your supporting documentation. A lawyer can assist in preparing and submitting these forms to ensure everything is accurate and complete.
- Attend a Hearing – In some cases, an appeal may lead to a hearing where you can present your case. This is often an opportunity for you and your lawyer to explain the circumstances of your injury and why you believe you should receive workers’ compensation benefits. A lawyer can prepare you for the hearing, explain the questions they may ask you, and advocate on your behalf.
- Follow-Up – After the hearing, your lawyer will monitor the situation and inform you of any developments or additional steps you may need to take.
Navigating a workers’ compensation claim denial can present challenges, but by following these steps and seeking the assistance of a qualified lawyer, you can improve your chances of a successful appeal.
Contact an Experienced Workers’ Compensation Lawyer Today
A knowledgeable workers’ compensation attorney in your jurisdiction can handle every step of the claims-filing process for you. Moreover, if workers’ comp denies your claim, your lawyer can appeal it for you and pursue the full benefits you deserve.
