- November 11, 2022
- Attorney David Mann
- Workers' Compensation
There are some Google searches we don’t ever want to make, and “What to do if my workers’ comp claim is denied” is one of them.
If you’re facing that dreaded situation, you might feel frustrated and powerless. But like David facing Goliath, you’re not alone. Workers’ compensation attorneys are here to help you get the money you need — even if the insurance company has already said “no.”
“What to Do If My Workers’ Comp Claim Is Denied”: A Step-By-Step Plan
When you get that “no” from the insurance company, it seems like the end of the story. You’re tempted to throw in the towel, a scary prospect when you’re injured and can’t work.
Whatever you do, don’t give up. “Workers’ comp claim denied” is a difficult bump in the road, but you can overcome it with help. Here’s how:
- Know your rights. Use our resources to learn about workplace injury law and who qualifies for compensation.
- Get an attorney. Attorney David Mann has experience working with insurance companies and knows the techniques they use. Call us at (478) 742-3381 to get help today.
- Request a hearing. You have the right to dispute the denial in front of the State Board of Workers’ Compensation (SBWC). File a WC-14 Notice of Claim form to request your hearing.
- (If necessary) Appeal the Board’s decision. There are multiple levels of appeal you can go through, all the way up to the Supreme Court of Georgia.
You have the right to attorney representation at all levels of your appeal process. The insurance companies have powerful lawyers on their side. You deserve the same.
Who Qualifies for Workers’ Comp in Georgia?
In the state of Georgia, all employers with three or more employees must have workers’ compensation insurance. You may file for benefits under that policy if you miss seven or more workdays due to a work-related injury or qualifying occupational illness.
As the injured party, you must notify your employer of the accident as soon as possible. Your employer must submit a WC-1 Employer’s First Report of Injury or Occupational Disease to the SBWC immediately after receiving your notice.
You may start receiving disability payments once you reach your eighth day of missed work. Payments are based on your duration and level of impairment and your pre-injury wage.
There are four types of workers’ comp benefits:
- Temporary total disability (you can’t work because of your injury): Two-thirds of your weekly wage up to a pre-set maximum
- Temporary partial disability (you can only work at a reduced level but expect to recover): Two-thirds of the difference between your current and pre-injury earnings
- Permanent disability (you are totally disabled with no foreseeable recovery): Two-thirds of your weekly wage for life
- Permanent partial disability (your function is permanently limited): Two-thirds of your weekly wage for a limited time, based on your degree of impairment
If you qualify for benefits but received a denial, a workers’ compensation attorney can help you figure out what to do — starting with why the denial occurred.
Reasons Why Workers’ Comp Claims Are Denied
Insurers deny workers’ comp claims for many different reasons. It does not mean your injury or disability isn’t real.
Often the issue is administrative. Missed deadlines and incomplete forms are common reasons for denial. In other situations, the employer claims that the incident didn’t happen as the claimant said.
Here are a few of the most common reasons for denial, plus what you can do about them.
Late or Incomplete Filing
Georgia state law gives you 30 days from when you were injured to notify your employer. Your notice must include the date, time, place, and cause of the accident. Include the details of what happened and the type of injury you suffered.
Verbal in-person notices are valid but difficult to verify. Your employer may claim that you didn’t notify the company within the 30-day window.
If you do miss the window, the insurer may deny your claim. You can appeal if you have a valid reason such as total incapacitation. You’ll also need to prove that your late notice did not harm your employer’s interests.
Missing or Incomplete Care Documentation
Your medical records are an important part of your workers’ compensation claim. If you don’t have medical proof of injury, the insurer is likely to deny your claim.
Even if you feel capable of recovering at home, you need to see a doctor after your injury. The insurance company will check those records to verify that the injury happened.
Your workplace must have a posted list of six or more doctors who provide covered treatment. In an emergency, however, any care qualifies. The important thing is to see a doctor who can document the validity of your injury.
If you didn’t see a doctor, talk with a workers’ compensation lawyer.
Incomplete Medical History
Your employer or a doctor may ask you if you’ve ever suffered an injury or event like the one that just happened. If you have and you fail to disclose it, intentionally or not, the insurance company may deny your claim.
Should that happen, you have the burden of proving either that (a) you did disclose the prior injury or (b) the incident was irrelevant.
Undocumented Time Off
If your workplace doesn’t have a formal timekeeping system, your employer might deny that you missed work due to injury. Your only recourse is to submit proof of your absences. Written documentation and witnesses are key.
Employees qualify for workers’ compensation benefits if they suffer an injury on the job. Some employers may deny either the “injury” or the “on the job” part of that legal requirement.
For example, if you suffer an injury while working alone and no one is there to see it, your employer might claim that you were injured on the way to work or during your off hours.
Employers might also claim that your injury happened due to personal negligence. An unwitnessed injury is your biggest risk here, too.
Workers’ Comp Claim Denied. What’s Next?
Whatever the reason for your claim’s denial, we’re here for you. Googling “what to do if my workers’ comp claim is denied” may be your first step, but it shouldn’t be your last.
Step 1: Get a Lawyer
Insurance companies have teams of attorneys to minimize their financial losses. To level the playing field, you need a skilled workers’ compensation attorney on your side.
Attorney Mann has worked for a major insurance company as defense counsel. He understands the claims review process and the reasons why insurers deny benefits. More importantly, he understands what it takes to overturn those denials.
Fighting back against an insurance company is difficult, but with someone like Attorney Mann on your side, you don’t have to go it alone.
Step 2: Request a Hearing
If your employer’s insurance provider denies your claim, you have the right to file an appeal. In Georgia, that means presenting your case at a hearing before the SBWC.
A WC-14 Notice of Claim form is your official hearing request. According to the SBWC’s frequently asked questions page, your hearing date will usually be within 60 days of the Board’s receipt of your form.
You may request a hearing before securing a lawyer. If you do, you are responsible for any errors or omissions on your form.
Step 3: Appear Before the Judge
At your hearing, you will have the chance to present your case before an Administrative Law Judge. The judge’s job is to hear the facts from both sides and determine what benefits you should receive.
Your employer may have an attorney present during the hearing. Not having your own counsel puts you at a serious disadvantage.
Step 4 (if necessary): Appeal an Unfavorable Decision
If the judge doesn’t find in your favor, you have the right to appeal the decision. The first step is to argue your case before the SBWC’s Appellate Division, also known as the Full Board.
If the Board denies your claim, you have 20 days to file an appeal with the state superior court. You must file the appeal in writing, stating your grounds.
Once the SBWC has filed all paperwork with the state superior court, you have 60 days to bring the case forward. You must give your employer 10 days’ written notice in advance of any court date.
If the Superior Court denies your claim, you can advance your case to the Georgia Court of Appeals and finally to the Supreme Court of Georgia.
The process can get complicated and intimidating, especially if you have to interact with higher-level courts. It’s important to have legal counsel to ensure you do everything correctly and get the settlement you deserve.
What to Do If My Workers’ Comp Claim Is Denied: First Steps
As law professionals in workers’ compensation practice, we understand how difficult and stressful it can be to secure benefits. We know you’re dealing with that stress on top of the difficulties involved in being out of work.
If your work has caused you illness or injury, you shouldn’t have to fight alone. Our experienced attorneys have helped many people like you get the benefits they need to stay afloat.
Call the Mann Law Firm at (478) 742-3381 or visit our website for a free initial consultation to get expert help filing or appealing a denial.