Even if you take all the steps you’re supposed to make your workers’ compensation claim, there’s still a chance that your claim could be denied. Your employer might be trying to avoid a claim on their record, the insurance company may not want to pay, or you may have made a mistake. If you get a workers’ compensation denial letter, it doesn’t mean that the decision is final. Here’s what you should do next.
Understand the Reason for the Denial
There are many reasons you might be denied workers’ comp. How hard it is to change the denial and what you need to do depends on the reason your claim was denied.
You Didn’t Report the Injury to Your Employer in Time
Florida law says you should report your injury to your employer as soon as possible and no later than 30 days. Your employer also has legal rights in a worker’s compensation claim, and they can’t exercise their rights without knowing about the claim. Since this law is about fairness, there are also exceptions where you can bring a claim after 30 days.
- Your employer or employer’s agent (for example, a manager) had actual knowledge of your injury
- The cause of your injury couldn’t be identified without a medical opinion, and you notified your employer within 30 days of receiving that medical opinion
- Your employer failed to post the required workers’ compensation notices advising employees of the requirement to notify them of injuries
- Other exceptional circumstances that justify your failure to notify your employer in time
Your Employer Didn’t Notify the Insurance Company in Time
In Florida, your employer is required to notify their workers’ compensation insurance company of a claim within seven days of being informed about your injury. If they fail to do so, you have the right to notify the insurance company directly. If you need assistance notifying the insurance company, you can call the state Employee Assistance Office. As a general rule, if you can show that you took reasonable steps to notify the insurance company after your employer failed to notify them, your employer’s failure to notify them won’t bar your claim.
The Cause of Your Injury Is in Dispute
Your employer may dispute the cause of your injury. One of the most common reasons is that your employer says your injury happened outside of work. They may also claim that you were injured due to your own conduct such as coming to work intoxicated or engaging in horseplay.
Generally, if you make a small mistake or procedure violation, you can still make a workers’ compensation claim. Further, if your employer or supervisor pressures you to violate safety rules to save time or for other reasons, those violations generally can’t be held against you.
You Didn’t Get Medical Treatment
As a general rule, you can’t receive workers’ compensation benefits if you don’t get or need medical treatment. In some situations, you may not realize the seriousness of your injury or your need for medical care until later. You will likely need to see a doctor before your claim can continue, but the fact that you haven’t yet gone to a doctor may not permanently bar your claim.
There is Nothing to Compensate You for
The insurance company may say that you were injured but there is nothing to compensate you for. They may say that your medical bills were already covered or that you’re able to return to work without a loss in pay. If you need additional treatment or don’t believe you’re able to return to work, you have the right to show why you’re entitled to more compensation.
You Left Your Job
If you leave a job before filing for workers’ comp, the insurance company may be skeptical of your claim because it may seem like you’re retaliating against your former employer. However, if you left your job because of your injury or not understanding your rights, it may still be possible to prove your injury happened at your former job. If your employer fired you for reporting the injury or trying to receive benefits, this is generally illegal and can give you a separate reason for a lawsuit.
What Can You Do If Your Workers’ Comp Claim Is Denied?
Once you understand the reason your workers’ comp claim was denied, it’s important to act quickly. You only have a limited amount of time to appeal, and not responding in time could mean that you lose the right to receive workers’ compensation. Here are the steps you can take.
Work with Your Employer and the Insurance Company
Not every claim will result in a legal battle. Sometimes, it’s something simple like you forgot to fill out a form or your employer wants you to see their own doctor. Your denial letter will explain the reason why your claim was denied. You can then provide additional information or further discuss the situation to see if that resolves the issue.
There can be downsides to trying to work through things informally, though. If you leave out information or incorrectly describe what happened, the insurance company may use that against you. For example, say you injured your back while lifting something at work and also fell off of a ladder at home a few weeks prior to that. The insurance company and your employer may argue that your injury is actually from the fall at home. If you talk to them, they may try to get you to say something that supports their view of the facts. If you have any doubts about whether trying to work with your employer or the insurance company can hurt you, talk to a workers’ compensation lawyer first.
File a Petition for Benefits
If you can’t reach a resolution with your employer and the insurance company, the next step is filing a petition for benefits. You do this with the Florida Department of Financial Services, Division of Worker’s Compensation, Bureau of Employee Assistance and Ombudsman Office. This is a formal appeal of the insurance company’s workers’ compensation decision.
You will need to provide documentation showing the nature of your injury, what benefits you believe you’re entitled to, and why you believe the insurance company is wrong. You have the right to have a workers’ compensation lawyer file this petition for you and should consider doing so since it’s an important legal document that can affect your rights.
Your employer will receive a copy of your petition and has 14 days to respond. Sometimes, this can result in additional informal talks that can resolve the situation.
If your employer and the insurance company still deny your claim, the next step is formal mediation. The EAO also manages this process. Mediation brings in a neutral third party for an informal hearing. Both you and your employer get a chance to explain your positions further. Unlike a trial, the mediator doesn’t make any binding decisions but may ask questions or make suggestions to try to help you come to a settlement. Whether or not you agree to settle at this point is completely voluntary.
If you don’t agree to a settlement after mediation, the next step is pre-trial hearings. Florida has a special workers’ compensation court called the Office of the Judges of Compensation Claims. During pre-trial hearings, you and the insurance company will submit formal explanations of your claims. You may also exchange additional evidence.
The purpose of the pre-trial hearings is for the court to be able to understand each side’s claim. It also allows the parties to prepare for a trial by making sure that they have all of the evidence and there won’t be any surprises. As the parties gather more information, there is often a chance for a last-minute settlement since they may gain a new understanding of the facts or their legal position.
If you’re not able to reach a settlement, you will have a final hearing or trial in front of a judge. The process is similar to trials you may have seen on TV. Both you and your employer can present evidence and call witnesses to testify. You can also cross-examine your employer’s witnesses.
The judge will issue a written ruling based on the evidence presented. This could be to give you all of the benefits you requested, to stick with the insurance company’s original decision, or somewhere in between.
If the trial judge rules against you, you can appeal to the District Court of Appeals. Unlike in the trial, you do not present new evidence to further support your claim. Instead, an appeal is where you make legal arguments about why the judge made the wrong ruling based on the evidence presented. The appeals court may confirm the judge’s decision or change the judge’s decision. The appeals court may also send your case back to the trial court and tell the trial court to make additional findings related to your appeal.
Get Help from an Experienced Workers’ Compensation Lawyer
If you’ve been denied workers’ comp, don’t try to navigate the complicated appeals process on your own. The experienced workers’ compensation lawyers at Feldman Legal Group can help you make sure you complete each step of the process properly while protecting your legal rights. To learn more about how we can help, call 877-946-8293 to request a case assessment.