Workers Compensation is the insurance that provides lost wages, rehabilitation costs and, medical benefits to individuals who fall ill or get injured at work. The wage and medical benefits vary with every state.
It can also be termed social insurance since it is a social contract between the labor and the employer. However, there can be incidents where the employees may face issues with the worker’s compensation denial & appeals. The causes of which will be discussed later in the article.
When faced with workers compensation denial by the employer, you can contact a lawyer who will help retrieve the lost benefits. Any business or employer who fails to provide the employees with Workers Compensation is subject to a loss of business in some cases as well. For more information in this regard, check out Calhoon and Kaminsky P.C.
This insurance is purchased by a business and either underwritten by an insurance company or by publicly supported state funds. The insurance also provides death benefits to the deceased’s family if they pass away while working.
How does the Compensation Work?
All states follow their rules when it comes to worker’s Compensation. However, some general conditions are considered in almost all states. Let’s have a look at them;
- The employees can only claim the insurance if the injury or illness occurred at the worksite. For example, an injury that resulted from a strain or fall or while operating the machinery are cases where the employee can claim for insurance.
- The employers ensure the workers of complete coverage providence.
- The injured individual must visit a health professional immediately. The physician will provide a medical report that is capable of supporting the claim.
- The claim and medical report, along with any other mandatory paperwork, is then submitted for approval.
- Once approved, the employee can receive their compensation cost and can return to work when they are ready.
When Is the Compensation not Provided?
There are a few incidents where compensation is not provided. These include;
- If the injury occurred was the consequence of the employee being under a drug or alcohol influence.
- If the injury was caused when the individual was not following the proper protocol or was intentional.
- The insurance will not cover any accident or condition that occurred except the workplace.
Compensation Cost Determination Procedure
Businesses of similar nature exhibiting similar workplace injuries and costs are all grouped in different classes. The compensation costs are then determined depending on the business’s lost costs in the past five years.
This allows equal distribution of the rates according to the loss experience of every class. The economic factors are also considered when determining the rates for different categories.
“Experience Rating” is a process that allows modification of rates depending on the loss history of the business. Safe businesses are provided with lower premiums as compared to unsafe businesses.
Almost all sorts of businesses in every state provide workers compensation, but there are some incidents where worker’s compensation is not provided.
For example, a few states do not provide worker’s insurance to seasonal employees, agricultural employees, independent contractors, and others. Make sure you contact the state’s government to check if you are provided with the insurance or not.
Incidents where the Worker’s Compensation can be Denied
There are several different incidences where the worker’s compensation is denied, and the matter needs the involvement of an attorney. Let’s have a look at them;
1. If the Injury was not Witnessed
If you claim the insurance for an injury that was not reported and has no witnesses, chances are the compensation claim may get denied. To avoid this, make sure to report the damage to your colleagues or your supervisor immediately.
Inform them regarding every detail on the injury. This will be helpful when asked for any witnesses who support the claim.
2. The Incident was not Reported in Time
An essential condition for worker’s compensation, as mentioned earlier, is that the incident should be reported immediately. Certain states’ rules require the workers to report the incident within a specific period.
By doing this only, they will be provided with worker’s Compensation. If you end up with an injury that you assume will affect your working efficiency, report it as soon as possible.
Make sure to fill an accident report. This will comply with the law and increase your chances of getting the help you need as soon as possible.
3. Presence Of any Discrepancy in your Statements
Consistency of your statements is the key. Avoid any discrepancy in the statements you make. A mismatch in the statement you made with your supervisor and your physician could lead to a denial of your compensation claim.
4. A presence of Illegal Drugs in your System
As mentioned earlier in the article, if the medical reports after an accident indicate the presence of drugs or alcohol in the body, the compensation claim is automatically rejected. The employee cannot ask for the worker’s compensation in such cases.
5. Claiming the Compensation after getting Fired
If an individual files an insurance claim after they get fired, the request will be denied. It may become difficult to convince the authorities to provide the claim.
The claim may also be denied if the employee is laid off. This is also one reason not to delay the compensation claim if you face an unfortunate condition.
When to Contact an Attorney?
Incidences involving any dispute between you and the insurer regarding the Compensation require the interference of a lawyer. Besides hiring an attorney, you also need to take some essential steps that include a deposition, an independent medical examination, and expert witnesses. Examples of such cases have been discussed below;
1. Unfair Claim Denial
Beware of insurance scams. Some companies may deny the insurance because the claim was not made on time or the injury was not work-related. Cases like this need professional attention.
The appeal process varies with every state. Whereas the general process followed requires the employee to gather legal evidence, fill in formal paperwork and ensure their presence at the hearing.
2. Disputed Disability Rate
A decent portion of the worker’s compensation is dependent on the disability rate. At times the company may not agree to provide you with the payment by not conforming to the disability rate.
The company may assign you to a physician of their choice. These healthcare professionals will give you a lower disability rate.
This assigned rate will then be used by the company to justify its denial. Make sure to contact a lawyer in such cases for a fair settlement.
3. A Pre-existing Condition
Any pre-existing condition affected by an accident at work is also a case where the Compensation is more likely to be denied. The injury can also be blamed on the situation and not because of the accident. To claim the Compensation in such cases, make sure you contact an attorney.
4. Any Trouble with getting the Treatment
Some companies may also deny the worker’s Compensation because of high treatment expenses, such as for surgeries. This may interfere with your treatment procedures.
An attorney will help you in this regard by pressurizing the insurance company to approve your claim. This will allow you to get the timely treatment you need.
5. The Accident has Permanently Affected your Working Ability
If an accident or injury has permanently damaged your working efficiency, you will need maximized workers’ compensation benefits. The benefits will have to be structured in such a way that they can aid you in the future as well.
Along with this, if you have to change your career and secure training in that specific area, hiring a lawyer will benefit you. An attorney can help you in both regards.
6. When the Insurer asks for a Recorded Statement
Some insurers will ask the employee for a recorded statement that describes the details of the accident. The statement usually includes information on how the accident occurred and what injuries occurred.
The general rules do not require the employees to give a recorded statement to the insurers. If the employee disagrees with issuing an invoice, they may be denied from the Compensation. The employee should hire a lawyer to deal with such cases and claim their Compensation.
7. If the Insurer asks to Sign a Medical Authorization
Some incidents involve the insurers asking the employee to sign a medical authorization. By getting the employee to sign this, the insurer gains direct access to the employee’s medical records and bills.
Again, according to the general rules, the claimer is not required to sign such authorization. The injured individual must get the medical records on their own and then submit them to the insurer.
Allowing access through the medical authorization puts the individual’s privacy at risk, and the insurer can also gain access to other health records. If an insurer pressurizes you to sign a medical authorization, it is recommended to contact an attorney. The attorney will help in claiming the worker’s compensation and will also be responsible for dealing with the matter professionally.