What Happens When A Claim Has Been Denied?
Last updated on July 29, 2024
If you are an injured worker, you are probably interested in getting your medical treatment paid (and compensation while you are off work and recovering) so you can get better and return to work as soon as possible. If your worker’s compensation claim has been denied after an independent medical examination (IME) or for any other reason, you must file an application for a hearing so that a judge can determine whether the denial is justified. Your next step should be to get in touch with a workers’ compensation attorney.
The attorneys at Domer Law, wrote the book on Wisconsin workers’ compensation law. We have over 80 years of combined experience in the workers’ compensation claims and hearing process. We have built a strong record of success in these claims and are dedicated to helping clients get the benefits they need.
Why Insurance Providers Are Not Your Friends
Sometimes, a claim is quickly approved and there is generally no reason to get a lawyer involved. Sometimes, however, the injury is more serious and takes longer to heal. In many situations, the injury is serious enough that it prevents you from returning to your line of work. When the injury is serious, the financial exposure to the insurance carrier is greater. Insurance carriers are experts at developing defenses for workers’ compensation claims. Insurance carriers hire claims adjusters to ensure that the carrier pays as little money as possible to resolve workers’ compensation claims. Remember, the insurance carrier and insurance adjuster is not your friend.
Often, the insurance carrier will send the injured worker to one of a handful of doctors it hires for what is called an IME (“independent” medical examiner). Frequently, these doctors will issue an opinion that differs from that of the injured worker’s doctor in regard to what further treatment is necessary or whether or not the person can return to work. It is at this point that the injured worker receives notification that his or her claim has been denied. In these situations, you need a lawyer who can assist you with claims and hearings.
Also, many insurance companies do not deny a claim outright; rather, the adjuster indicates they are “investigating” the claim for a lengthy period of time. If an injured worker has not been paid worker’s compensation benefits and has been off work for more than two (2) weeks, they should consult with an attorney to push for benefits if there is medical support.
How To Appeal A Denied Claim?
If your workers’ compensation claim is denied by the insurance company, an injured worker’s recourse is to file an Application for Hearing with the state Department of Workforce Development (DWD). This application notifies the insurance company that there is a dispute in the case and the DWD will serve the hearing application on the insurance company. The insurance company then must file an Answer to determine what issues are in dispute.
The next step is to file all necessary evidence before a hearing occurs. Generally, an experienced worker’s compensation attorney can assist in this process. Necessary information includes certified medical records; medical support from treating doctors (through a WKC-16B form); vocational reports; and medical treatment statements (with itemizations of medical bills).
What You Need To For Your Appeal
To effectively prepare for an ALJ hearing, it is important to gather all necessary documents, including certified medical reports (including a WKC-16B form) and a medical treatment statement (called a WKC-3, attaching itemized billing statements). These should be filed with the Division and the insurance carrier’s attorney at least 15 days before the hearing. Additionally, ensure you contact and arrange for necessary witnesses to attend the hearing. If you plan to present evidence regarding loss of earning capacity, notify the Division and name your expert witness at least 60 days before the hearing. Proper preparation with comprehensive evidence is key to supporting your case.
A litigated hearing is a “mini-trial.” There will be an Administrative Law Judge and a court report (who can create a transcript of the hearing). The injured worker will provide testimony under oath about relevant facts of the injury, medical care, and employment status. The insurance company defense attorney has the right to cross-examination as well. Both sides can also bring other relevant witnesses to testify.
Following the hearing, the Administrative Law Judge has 90 days to issue a written decision. Whoever “loses” has the ability to appeal the case to the Labor and Industry Review Commission (LIRC), which are three political appointees who make the final decision on worker’s compensation. An appeal from LIRC can go to the circuit court system.
How An Attorney Can Help You With Your Appeal
An attorney can significantly assist you by guiding you through the complexities of appealing a denied workers’ compensation claim. They can help by preparing and filing the necessary legal documents, representing you at your hearing and advocating for you before the Administrative Law Judge. Additionally, an attorney can assist in gathering and presenting the required medical evidence and expert testimony to substantiate your claim. With a lawyer on your side, you can navigate the appeal process more effectively and increase your chances of a favorable outcome.
If Your Claim Has Been Denied, Get A FREE Consultation
At Domer Law, our job is to force the insurance carrier to pay the benefits that are due – nothing more and nothing less. If your claim has been denied, we will try to help. Send us an email or call our Waukesha number at 262-333-1938, or call our Milwaukee office at 414-279-2647 to schedule your free initial consultation. In all cases, we do not recover attorneys’ fees unless you recover wage benefits.