What to Do if Your Workers Compensation Claim is Denied

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I wanted to talk to you in this article about what to do if your workers compensation case is denied. This happens more often than not actually it’s something that occurs quite frequently. Up to 80 percent of these cases at some point are denied for one reason or another.

So, what should you do if you’re handling your case on your own and suddenly the insurance company says they’re not paying any more benefits. If they inform you that they’re not paying any more medical care and they’re now disputing your case?

First of all let’s look at why your case might be accepted and then suddenly denied. The first thing that can cause your claim to be denied is if you didn’t give your employer proper notice of the accident. It’s true that in Illinois you have 45 days from the date of your accident to give your employer notice, but try not to wait that long. If you know you’ve been injured report it as soon as you can.

The longer you go, even with an injury that might be obvious… the longer you go without telling your employer that you had an accident, the more likely your case will be disputed. Memories fade.  Supervisors change. People somehow don’t always remember that a worker told them about an accident, especially if you don’t mention it for 45 days.

The next factor that could negatively affect your case is that maybe the company the insurance company has decided that you didn’t have an accident at work.

An “accident at work” doesn’t just mean that you weren’t hurt at the workplace; it could mean that they’re claiming you didn’t have an accident that arose out of and in the course of your employment.

A couple of examples of these might be if I am at my office I’m working and I bend over to tie my shoe and somehow all of a sudden I have back pain. Say the pain turns out to indicate a herniated disk. The insurance company will argue that that isn’t something that arose out of and in the scope of my employment because I wasn’t doing anything in the furtherance of my work. In other words, I wasn’t doing anything associated with my job at Kirkpatrick law offices.

However to look at another example, assume that part of my job sometimes requires carrying these files back and forth. Some of them are large, and if I bend over

and pick up a file that weighs 45 pounds to carry it across the office resulting in back pain, then I am then doing something associated with my work.

A lot of times the issue of accident arises if a person has an accident in a parking lot or if they fall walking across the floor at the office and trip over their own feet or they’re climbing stairs with nothing in their hands. Many times the insurance company will dispute those cases because they resulted from circumstances not in furtherance of your actual work.

The next thing to be aware of to keep your case from being denied is that you have to prove that there is a causal relationship between your condition and your work.  Let’s say that you have a torn cartilage in your knee from the accident that you suffered at work. Many times the insurance companies will be fine with paying someone for a knee strain and going to the doctor to get a few x-rays. However, when it turns out that the injury is something more and an MRI or surgery is needed  the insurance company will then try to put a stop to your claim.

One tactic they will use is to send you to another doctor who will likely say that you don’t need surgery or you don’t need the MRI or even that you don’t need any additional treatment. Suddenly they’re claiming that you’re fine or that the accident that you had at work has nothing to do with the problem you’ve got with your knee. You might be surprised to hear from them that they believe your problem came from being a high school football player 35 years ago. They actually come up with that sort of thing!

If your case is denied really quite honestly you probably don’t have much choice at that point but to hire a workers compensation lawyer who knows what they’re

doing. Once you hire a lawyer he or she files the claim and many times these cases have to go to arbitration. This is where an arbitrator decides whether what happened to you constituted an accident at work.

Lawyers can also help you prove causation. Sometimes you need a lawyer to take a deposition of your treating doctor. In this type of deposition, your doctor can testify to the specifics of for example how by climbing off the piece of equipment and landing wrong on your foot you, in fact, twisted your knee and caused a meniscus tear or something of that sort. You’ll need those sort of things to move your case forward and in order to win it.

The workers compensation act gives you many rights. It tells you everything that you’re entitled to in Illinois. Incidentally, Illiniois is probably one of the most

liberal states in our area in terms of workers compensation. You want to avoid ever getting hurt in Kentucky or Indiana and even Missouri because their laws are

not as favorable to the petitioner.

So it’s sometimes true that your remedy is to hire a workman’s compensation lawyer if your case is denied on any of those factors.

Most of the disputes that I encounter come about related to the causation aspect. Disputes to accident causation usually come by way of your hearing from the insurance company when it comes time for some sort of surgery or expensive treatment. They’ll claim your injury is related to arthritis even though you’ve

never had any problems before and all they need is a medical opinion. They can dispute your case and make you prove it to the workers compensation arbitrator they don’t have to accept your claim.

If you’re handling your own case there are certain things you can do to avoid your case being denied. Let’s to go back through the same things we’ve talked about.

Report your accident immediately.  Don’t have an accident on a Friday and think well I’ll report it Monday. That is a red flag to the insurance company and your

employer that you probably weren’t hurt at work. If the accident happened on a Friday, Friday should have been the day that you reported it. Insurance companies will assume, especially in the summertime, that you’ve possibly been out on a boat somewhere. They like to throw that out or you were doing some sort of summer activity. In the wintertime they’ll try to claim well you might have been out shoveling snow or that sort of thing.

Report your accident immediately, and report it to a supervisor! Telling your co-worker that you hurt your back while lifting a heavy box or crate doesn’t suffice for notice. You have to tell a  supervisor even if you think it’s not going to be a big deal. It doesn’t have to be on a written form, but you make sure that you tell a

supervisor.

On a related note, many people claim that their employer would never do the wrong thing. Your employer may be the best employer in the world. You may get along with them just fine. They may think you’re the greatest employee who ever lived; however 99 out of 100 times when you are injured, your case goes to an insurance company. It’s the insurance company that’s out there to have to pay your medical bills and your time off work and then the permanency award if there is one. You are nothing to that insurance company other than a number, and they’re going to try to get away with paying you as little as possible. Their interest is completely contrary to yours.

I say this because even though people think that their employer is the greatest, sometimes the insurance company won’t listen to the employer at all. In fact, sometimes the insurance company comes to you and asks you to sign an authorization. They’ll claim that it just lets them get access your records.

I caution you to read that authorization closely or have your attorney read it. Sometimes that authorization will also say that the insurance company gets to write to your doctor to get reports or to let them talk to your doctor outside of your presence. The agreement might say that you agree to let the insurance company call

your doctor and talk to him without you being there. It might say that you agree to let the insurance company send videos to your doctor or other information pertaining to your case.

You absolutely do not want that to happen.The reason is that you have the right to privacy between you and your doctor. The workers compensation act allows insurance companies to get the records and the records only. I have a case right now where the client signed an authorization allowing the insurance company to talk to his doctor. This agreement was signed by the injured individual before I was ever involved with their case.

The insurance company decided to send the doctor a video of this man doing something that appeared damaging in terms of his injury claims. The video really didn’t matter in the grand scheme of things but they had the opportunity to make it look 10 times worse than it was.  Then the doctor, without my client’s knowledge thought he was demonstrating in the video that he could go back to work full duty. My client didn’t know that he was released at full-duty. It all happened behind his back due to his signing of that authorization.

Don’t sign authorization without limiting it to state that this does not permit ex parte communication or in other words this does not allow the insurance company or its agents to talk to my doctor outside of my presence. Period.That’s the rule. That’s the Law.   

Whenever you see a new doctor you need to make sure that that doctor knows the history of your accident. Always give the doctor a detailed history of exactly what happened to you. Don’t assume that the insurance company gave him a history don’t assume that your doctor knows about your claim.  If you don’t tell the doctor what happened, when it comes time to prove that there’s a causal relationship, as I referenced earlier, the doctor is not going to have a history in his notes. That seemingly small omission will come back to haunt you when you then have to prove that you really did have this accident that caused your injuries.

Arbitrators can get a confused and a big deal can be made out of the fact that you haven’t reported to your doctor the accident. If you don’t report the accident then the doctor has a hard time testifying that an accident you had caused the condition that you are suffering with.

When the insurance company decides they’ve had enough and they’re not interested in paying for surgery and they can send you to a doctor of their own choosing for an evaluation. I always tell people facing these examining doctors to be themselves. Don’t over-complain. Don’t give the doctor any reason to suspect that you’re lying or exaggerating. Answer the doctor’s questions. Don’t tell him any more than he asks and, again,  make sure that you give a detailed history of the injury and the accident.

I tell folks keep track of the time that you spend with that examining doctor because oftentimes the doctors will generate a five-page report and when I ask the client how often or how long they spent with the doctor it might have only been five minutes. You can see a lot of the rest of the note is just a summary of medical records based on what the doctor wanted to put down rather than information truly indicative of the nature of the case and the injury.

If your case has been denied you likely do need to hire a lawyer and make sure it’s an experienced workers compensation lawyer. If you are trying to pursue the case on your own, I’ve given you some good information on what you should and shouldn’t do.