Solutions to Common Issues With Workers’ Comp Claims

The workers’ compensation insurance program was created to reduce the strain on the court system by giving injured employees faster and easier access to compensation.

However, the process of filing a claim and getting benefits can be frustrating and complicated. From delays to denials, roadblocks often prevent injured parties from getting the compensation they deserve.

If you’re struggling to get workers’ comp, here are some solutions you can try.

1. Hire a workers’ comp attorney

Hands down, the best way to move your situation forward is to get help from a workers’ compensation attorney. They’ll know exactly how to verify and value your claim to get you approved and compensated according to the law. For example, South Carolina’s workers’ comp minimum is 66+2/3% of a worker’s average weekly wage. Getting your claim approved isn’t enough; they have to pay you according to your state’s minimum.

Whether you’re being outright denied, or you aren’t getting the legally-required amount of weekly benefits, a workers’ comp attorney can help you get what you’re owed.

2. Talk to your employer

Although many employers mean well, some actively try to get claims denied to avoid paying higher premiums. As with any insurance policy, each time a claim is paid out, the policy holder’s rates increase.

This is an unavoidable part of doing business, but some employers will go to great lengths to stop employees from getting benefits. For instance, some will lie to say the injury didn’t happen at work, or they’ll claim it was the result of horseplay to make it ineligible.

If you suspect your employer is interfering with your ability to get compensation, try talking to them about the situation. Go prepared to remember and document your conversation so you have a record of what they say. Ask if they know why your claim has been denied, and see what they say. If it doesn’t match what you were told by the workers’ comp agent, take note, and let that be your cue to consult with an attorney.

3. Double-check for mistakes

There are several mistakes that can get a valid claim denied. These mistakes include incomplete or incorrect paperwork, missed deadlines, and unsubmitted evidence. Read your denial letter carefully because it might outline some of the reasons listed above. If you missed the deadline for filing your claim, there’s nothing you can do. However, if you still have time, correct the mistakes and submit an appeal.

4. File an appeal

workers’ comp appeal is a formal request made to a higher authority to review the decision to deny your claim. If you think a denial was the wrong decision, you have a right to request a review. However, a successful appeal requires being able to point out mistakes, like incorrect facts or a misapplication of the law. You can’t appeal a denial simply because you don’t like the decision. You need a good reason.

If you’ve done everything correctly, you met the deadline to file, and your claim has still been denied, file an appeal. It helps to have a lawyer file on your behalf, but that’s not necessary if you can identify why the denial was the wrong decision. If you aren’t sure, it doesn’t hurt to at least consult with a lawyer to find out if you have grounds for an appeal. However, keep in mind that it usually takes a lawyer to identify an error of law.

Keep in mind that when you file a workers’ comp appeal, most states will allow you to submit new evidence, but only if it wasn’t available when you first filed your claim. It can’t just be a rephrasing of evidence already submitted. And you’ll need to explain why you didn’t include the new evidence with your initial claim.

Good examples of new evidence include:

  • A conversation with your boss where they admitted to saying something untrue that led to your claim’s denial
  • Your medical condition has worsened
  • You receive a new diagnosis that significantly impacts your ability to work
  • You found a witness who was not available for your initial hearing

Once submitted, a board panel will review your appeal and either affirm the initial decision or reverse it and send it back for more review. In some states, you can appeal a denied appeal within the system and once again outside of the workers’ comp system.

Keep fighting

The workers’ comp system isn’t foolproof, and sometimes you need to fight to get your benefits.