Workers Comp Appeals Process

Workers’ compensation insurance can be beneficial to employers and their employees by providing financial protection to both parties. When the system works as it should, an employee who was injured in the course and scope of their job files a claim to receive reimbursement for medical bills and wage replacement. The insurance policy protects the employer from the threat of personal injury lawsuits by employees, and it protects the employee from having to pay for expenses related to their injury.

When a workers’ comp claim is denied, however, the employee is put in a difficult position. The existence of the policy can limit the legal action they are able to take against the employer. Fortunately, a personal injury attorney can offer assistance with the workers’ comp appeals process.

Why Are Workers’ Comp Claims Denied?

Common workers’ compensation denial reasons include the following: 

• The injury was not reported promptly. In Texas, you have 30 days to report an injury to your employer and one year to send a completed claim of compensation form to the Division of Workers’ Compensation. 
• The insurer argues that the injury was not related to the job. In order to qualify for workers’ comp benefits, the injury had to occur during the “course and scope” of your employment. That means that if you sustain an injury while deviating from your duties, that does not qualify for workers’ comp benefits (ex: you are traveling for work and decide to go sightseeing on your own time and get injured).
• The insurer argues that the injury was preexisting. People with a history of health problems such as back and neck pain may find their workers’ comp claim in jeopardy. Even if the particular injury is new — or the incident at work exacerbated an existing injury — the insurance company will claim that the job was not the major contributing cause. 
• The employee didn’t seek medical treatment. Visiting the doctor or hospital immediately after the incident creates a paper trail that proves the existence of the injury. Without that record, it’s easier for an insurance company to claim that you were not injured at all, that it didn’t happen at work, or that it was not serious enough to require medical care and therefore must not be causing you any real problems. 
• There were no witnesses. Documents are a key component of a successful claim, but witness statements can also be crucial. If no one can attest to the circumstances of your injury, it can be your word against your employer’s.

If your workers’ comp claim was denied for one of these reasons, contact a personal injury lawyer to discuss your case. 

What Recourse Do I Have if My Workers’ Comp Claim Has Been Denied?

A workers’ comp claim denial can leave you feeling frustrated and hopeless about your chances of recovering compensation, but your case doesn’t have to end there. The appeals process permits you to continue pursuing your claim. 

This step is more complicated than the initial claim submission, and you will want an attorney in your corner who can handle the negotiations. Your attorney will initiate a dispute resolution with the Division of Workers’ Compensation. During the dispute resolution, both parties meet together with a review officer and try to settle the claim through mediation. If the matter is not resolved and you do not receive a favorable outcome, your attorney will appeal once again, taking it all the way to state court if necessary.

How Can Aaron Allison Help? 

If your workers’ comp claim was denied, that does not mean it was illegitimate or that it is no longer worth pursuing; it means you need an advocate with the knowledge and resources to settle the case and produce a just outcome. At the Law Offices of Aaron Allison, our experienced workers’ compensation attorney will navigate the red tape to increase your chances of securing fair financial recovery for your workplace injury. Contact us online to schedule a free case review.