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What can I do if My Workers’ Comp Claim was Denied?

December 10, 2018

When you are hurt on the job, the injury should likely be covered by workers’ compensation insurance. Employers in Wisconsin are generally required to carry workers’ comp insurance if they have three or more employees. First and foremost, it is important that the workers’ comp claim is properly submitted and that you report the injury in a timely manner. It is common for workers’ compensation claims to be denied and insurance companies may not be helpful in working out claim issues. Instead, you may find that rather than getting workers’ comp payments you get a letter stating that your claim was denied.

Why Workers’ Comp Claims are Denied

There are many reasons why a workers’ comp claim may be denied. The first step in resolving the situation is to find out why the claim was denied. A claim may be partly or fully denied. This means that a portion of your claim might be paid while another part is not. It is helpful to seek legal counsel to assist you with your workers’ compensation claim.

Claims can be denied because they feel the injury did not occur at work, because the treatment is not reasonable, or for a wide range of other reasons. Keep in mind that the insurance company is a business that needs to make a profit. Therefore, they must question claims that they feel have not been satisfactorily proven. In some instances, you may be able to supply additional documentation or doctor’s reports that will prove your injuries.

What to do if Your Claim was Denied

If your claim was denied and you feel that you are owed benefits, you may file a dispute. Your dispute will be handled either informally or formally, depending on whether or not you have an attorney. Disputes without an attorney handling the claim will first be handled informally.

Claim disputes are handled through the Alternative Dispute Resolution Unit (ADR).

Your claim will be assigned to a specialist for further review. The specialist will review the reasons for the denial and evaluate the medical records and other documents to make a determination. If the ADR staff is able to resolve the problem without a hearing, they will contact you or your attorney to discuss the matter further.

If the matter cannot be resolved through the informal process, you are allowed to request a formal hearing. Formal hearings are in front of Administrative Law Judges (ALJs). In order to obtain a hearing, you must submit an application along with the required documentation that supports your claim. It is in your best interest to have representation at the hearing by an experienced workers’ compensation attorney.

The hearing in front of the ALJ is a legal proceeding. The judge will make a finding and an order based on the results of the hearing. If you disagree with the decision you have the right to appeal. You may appeal the decision with the State of Wisconsin Labor and Industry Review Commission (LIRC) who will review the case and make a decision. If you still disagree with the findings, you can appeal to the appropriate circuit court.

If you feel your workers’ comp claim was denied unjustly, we can help. Contact our experienced lawyers at Moen Sheehan Meyer, Ltd. to discuss your case today.

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