Why Would My Employer Deny My Claim?

Did the injury occur at work? The answer to why an employer would dispute a workers' comp claim is simple and boils down to a single five letter word: money. Like any other type of insurance product, employers pay premiums to provide workers' compensation benefits to workers (in most states, this is mandatory). Premium amounts are directly affected when injured workers file for benefits. Premium Costs Logically, the more workers' comp claims that are filed, the higher the costs for employers. Workers' comp insurance premiums increase when more workers than estimated file for claims, or when an employee has a particularly expensive claim (for instance, requiring back surgery). It is for this reason that employers and their insurance companies routinely use investigative agencies to monitor the daily activities of workers who have filed workers' compensation claims. Employer Bias Unfortunately, many employers don't believe that some injuries are serious or even valid, especially cumulative trauma injuries. They assume that a worker who files for workers' compensation benefits on the basis of carpal tunnel syndrome, another repetitive stress injury, or a lumbar back injury is not being completely truthful (or is "malingering," the industry term for feigning sickness or disability for financial gain). Employer bias is particularly strong against injuries involving inexplicable pain that cannot be wholly verified by medical examination, or even sufficiently verified by x-rays, other imaging, or nerve conduction studies. Does this mean that the injured worker who has constant back pain is malingering? Definitely not. Many medical conditions are difficult to objectively verify. Reasons for Denial of a Claim If your employer or its insurance company denies your claim, or any part of it, it should inform you in writing. Typical reasons given for denying a claim are: You didn't suffer a serious injury. Your injury didn't take place during work, or within the scope of employment. You don't need medical treatment for your injury. You don't need time off work for your injury. Fighting a Denial of Benefits If you receive a notice that your claim has been denied, call or write to your employer's workers' comp insurance carrier. If this doesn't solve the problem, hire a workers' comp lawyer and request a hearing with the state workers' comp board. The bottom line is this: employees who have become injured or sick as a result of their job should file for workers' comp to protect themselves, and if their claim is denied, they should fight the insurance company, with the help of a lawyer. Whether or not the employer believes that the worker is legitimately injured will turn out to be irrelevant, and the worker shouldn't worry about whether the employer holds the employee in contempt for filing a claim. It is the worker's right to have time off work and medical treatment paid for; the worker has given up the right to sue the employer in exchange for the workers' comp benefits and should not feel guilty about using them.

Why do I Need A Board Certified Workers Compensation Specialist?

I was injured at work in Connecticut. There was a witness. My contact at human resources assisted me with completing an incident report. I was on the clock and on the employer's premises when I was injured. Why won't the insurance company pay my benefits? Why am I waiting for medical treatment to be authorized? What appear to be the most frequently asked questions by injured workers immediately following a work injury become increasingly more difficult to answer as time moves on during the pendency of a claim. The Workers' Compensation Act has evolved a long way since its' inception in 1913. However, several themes remain true and stand the test of time. First, Connecticut's Workers' Compensation Act (the "Act") is meant to compensate the injured worker for their finanical loss and in particular - the weekly rate of pay that the employee lost as a result of the injury. If you are unable to perform any gainful employment as a result of the injury the Act protects against that loss. The inability to work must be substantiated by a physician. Once submitted, the employee gets paid her base compensation rate (a percentage of her average weekly rate) which happens to be non-taxable under the Act. Where is my check? Well, upon further review the insurance carrier's responsible adjuster is not volunarily paying until they hit a few items on their checklist. Wages verification from the employer. Obtain confirmation from the first call center as to loss of work capacity. Are there restrictions? Can the employer accomodate the injured employee's circumstances? Has the employee completed the proper forms to determine an average weekly wage or base compensation rate? Making matters more difficult, the injured worker's focus should be on getting better. The process of obtaining authorization for initial medical treatment from the responsible workers' compensation carrier can be an extremely difficult task especially for an individual and her family that did not expect to be thrust into difficult circumstances in an instant. Who is the carrier? Who is the adjuster? How difficult is it to get me a claim number? Why is this nurse calling me and why is he allowed to walk into my doctor's office with me? How come I have to go to this urgent call center so many times without getting a referral to a specialist physician? Another theme that stands the test of time is that the Act ensures the injured worker access to "reasonable and necessary" medical treatment. Again, this seems like an easy problem to solve. I'm hurt at work. Get me to a doctor. I have spent more time litigating an injured worker's right to proper care than I care to divulge. Why? It is costly. The process between physician office and responsible adjuster is cumbersome. The insurance carrier, much like the verifications made before making payment of lost earnings also needs to confirm several aspects of your medical picture before authorizing treatment. Has the injured worker signed the proper forms to obtain treatment? Was there a pre-existing injury or accident causing the need for treatment? Does the injured worker have private insurance to process the cost of medical treatment during our investigation? Has the doctor's office submitted the proper codes and documentation. Do you see the common theme here? Navigating your claim has become increasingly difficult given the delays involved from the onset with respect to payment of benefits and rendering of medical care. The cost of benefits and treatment to the carrier often drive the contest of any claim. Even in "accepted" claims, the carrier will often litigate matters of import throughout the course of the claim. Setting the tone early with the responsible workers' compensation carrier and claims adjuster when you have a serious work injury is important. Not every case necessitates the involvement of an attorney. However, it's extremely prudent to get the advice of one before the process gets out of hand.