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Steps to Take if the Insurance Company Refuses Your Workers' Compensation Claim

The workers' compensation system is a no-fault system, meaning an employer's workers' comp insurance company must pay out a claim regardless of whether or not the employee is responsible for his or her own injuries. However, just because the workers' comp system is no-fault does not mean that claims do not get denied. It is not uncommon for insurance companies to deny a workers' comp claim. If it happens to you, does it mean you are out of options, or are there steps you can take to reverse the decision?

Common Reasons for Workers' Comp Claim Denials

If the workers' compensation insurance company denies your claim, it will inform you in writing of the reason for the denial. Sometimes this reason is legitimate, while other times it may seem completely arbitrary. Whatever the case, it is important to allow an experienced attorney review the denial letter and determine if there is anything you can do to appeal it. Some common reasons for denial include the following:

● You did not sustain a serious enough injury to warrant workers' compensation benefits;

● You did not sustain your injury during working hours or within the scope of employment;

● Your injury does not warrant medical treatment;

● You failed to notify your employer of your injury or file your claim in a timely manner; or

● You do not need time off work to recover from your injury.

Appealing a Workers' Compensation Claim Denial

If you wish to appeal a denial decision, you can do one of two things — reopen your case or request an administrative hearing. You might reopen your case for any one of the following reasons:

● You discovered new evidence to support your claim;

● An administrative or legal error is the reason for the denial;

● Your injury has worsened, returned, or become aggravated;

● New evidence shows that the benefits you were awarded are unjust or inadequate; or

● Fraud is discovered.

Generally speaking, unless you discover new evidence to support your claim, you will not reopen your claim in response to a denial. Instead, you would request an administrative hearing, which is essentially the same thing as filing an appeal.

If you receive an administrative hearing, you will go before a judge to argue your case. Therefore, you need to be prepared with sufficient evidence and expert testimony to ensure your efforts are not for naught. It is at this point that you should retain the help of an experienced workers' compensation attorney.

The right attorney will gather all the necessary information from your doctor, devise a convincing argument for your disability, and, if they exist, uncover errors the Social Security Administration made that resulted in your denial.

For many people, workers' compensation benefits are the only reason they are able to stay afloat after sustaining a serious, work-related injury. If this is the case for you and your family, contact a Ponca City workers' compensation attorney right away. Contact Boettcher, Devinney, Ingle & Wicker to discuss options for appeal and to begin building your case.

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