When the workers’ compensation process works as intended, it benefits both injured employees and their employers. Injured employees receive the compensation they need for their medical expenses and lost wages in a timely fashion. At the same time, employers are protected from personal injury lawsuits arising from on-the-job accidents. However, the system doesn’t always work as intended because workers’ comp insurance companies are primarily concerned with their bottom lines.
If your workers’ comp claim was denied, it’s vital that you understand your rights and the steps you need to take to appeal the insurance company’s decision.
Common Reasons for Workers’ Compensation Denials
Before appealing your workers’ comp claim denial, it’s important to understand why your claim was denied in the first place. When an insurance company issues a denial, it must include the reason for its decision.
- Failure to Report the Injury: Injured workers in Georgia must report their injury to their employer within 30 days. Failure to report your injury within this period may result in losing your right to seek benefits and an automatic denial from the insurance company.
- Missed Deadline for Filing a Claim: In addition to the deadline for reporting your injury, there is a one-year deadline for filing your workers’ compensation claim. Failure to file your claim within this period will result in the insurance company denying it.
- Insufficient Evidence: Insurance companies may deny claims if you don’t provide sufficient evidence. Your evidence should demonstrate the severity of your injuries, the necessity for treatment, and the connection between your injuries and your employment.
- Pre-Existing Conditions: Sometimes, insurance companies deny claims due to pre-existing conditions. However, employees can seek compensation for the worsening of their pre-existing conditions due to their work.
- Injury Didn’t Occur at Work: Your employer or their insurance company may claim that workers’ compensation doesn’t cover your injury because it took place while you were off duty or in a non-work location. In this case, you must provide additional evidence connecting your injury to your work duties.
Understanding the Workers’ Compensation Appeal Process
After determining why your employer’s insurance company denied your claim, you can begin the next steps of the appeals process, which include filing for an appeal, attending a hearing with an administrative law judge, and potentially appealing the judge’s decision to the appellate division of the State Board of Workers’ Compensation.
To make this process run as smoothly as possible, it’s recommended that you work with an experienced workers’ compensation lawyer who can provide guidance and represent you throughout your appeal.
Filing a Form WC-14
Your appeal begins when you file a Form WC-14 with the State Board of Workers’ Compensation. Some of the information you must include on this form is:
- The names and contact information of all parties involved, including yourself, your attorney, your employer, their insurance company, and their attorney
- The reason for filing your claim with the board, including the benefits you are seeking
You must also send a copy of this form to the relevant parties so they can respond to your claim.
Attending a Hearing with an Administrative Law Judge
Once your Form WC-14 is submitted, the board will schedule a hearing before an administrative law judge. This hearing will take place within 60 days of the judge receiving your claim.
At the hearing, the judge will listen to arguments made by both sides and determine whether to uphold the denial. If the judge decides that your claim is valid, they will also determine what benefits you should receive based on the evidence presented.
It is in your best interest to have a lawyer represent you at this hearing. Each side only has a limited amount of time to make their case, and an experienced lawyer will understand the process and how to best use the time you have.
Appealing a Judge’s Decision
If the administrative law judge upholds the claim denial, this is not necessarily the end of your claim. Under Georgia law, any party dissatisfied with an administrative law judge’s decision can appeal that decision to the State Board of Workers’ Compensation’s appellate division. However, you must make this appeal within 20 days of the judge’s decision.
Common Mistakes Injured Workers Make When Appealing Claim Denials
Injured workers often make the same few mistakes when attempting to appeal their denied workers’ compensation claims. Here are some of the most common mistakes injured workers make during their appeals:
- Missing Appeal Deadlines: If you don’t begin receiving workers’ comp benefits after reporting your injury to your employer, you only have one year to file your Form WC-14 with the State Board of Workers’ Compensation. And if the administrative law judge upholds the claim denial, you only have 20 days to file an appeal with the appellate division.
- Improperly Filling Out Forms: It’s essential that you fill out the forms related to your claim properly so the administrative law judge and appellate division board have the correct information when assessing your claim.
- Failing to Provide Additional Evidence: As part of your appeal, you should provide additional evidence in response to the reason given by the insurance company for the denial. By submitting additional evidence, you will strengthen your case and increase the odds of a successful appeal.
- Failing to Hire a Workers’ Comp Lawyer: Hiring a workers’ compensation lawyer is one of the best things you can do for your case. An experienced and knowledgeable lawyer will handle all aspects of your appeal, from gathering evidence to filing your paperwork to representing you at your hearing.
Contact Our Augusta, Georgia, Workers’ Compensation Lawyers
If your workers’ compensation claim was denied in Augusta, Georgia, call Chris Hudson Law Group at (706) 863-6600 or contact us online for a free consultation with one of our experienced workers’ comp lawyers. During your initial consultation, we’ll review the details of your case, go over the reason the insurance company gave for denying your claim, and walk you through the process of filing a denied workers’ comp appeal with the State Board of Workers’ Compensation.