Workers' Comp Denials & Your Options

If your workers’ compensation claim was denied, your claims administrator has determined that your injury or illness is not covered under workers’ comp policies in Georgia. Fortunately, that doesn’t mean your claim for benefits is over.

Reasons for a Denial

After receiving a claim denial, you must try to figure out why the insurer did not approve it. The insurance carrier should send you a letter which explains why they denied your claim.

Common reasons for denial of workers’ comp benefits include, but are not limited to, the following:

  • Claim was not filed in time
  • Injury was not reported on time
  • Employer disputes claim
  • Insufficient evidence that injury occurred on the job
  • Failure to obtain medical treatment after suffering the injury
  • Injury is not compensable

Filing an Appeal

Once you receive a letter of denial, you have the right to appeal the insurance company’s decision. Along with the reason for denial, instructions for appealing the decision should be included in the letter.

You have the right to request a hearing before the State Board of Workers’ Compensation to appeal the denial of your workers’ compensation claim. The board can provide you with the paperwork necessary to obtain a hearing.

As soon as you finish the paperwork, send a copy to your employer and its workers’ comp insurer, and send the completed forms to the board. You will then be assigned a judge and a hearing date. In many cases, you will be required to undergo mediation before your hearing, in order to resolve the dispute. If you and your employer are unable to reach an agreement, the case will return to the administrative judge for a hearing.

A hearing is similar to a trial, with all of the rules of procedure and rules of evidence involved. You will have an opportunity to present evidence to prove that you are owed workers’ compensation benefits. Keep in mind, you must present live witness testimony, such as a doctor who has sufficient medical evidence to support the existence of your injury and the exact cause. Letters or statements are not admissible in the hearing.

The judge will review all of the admissible evidence presented and then issue a written decision regarding what benefits, if any, you should receive. If you disagree with the judge’s decision, you may appeal the decision to the Appellate Division of the State Board of Workers’ Compensation. You will have 20 days to do so.

While you may represent yourself, it is wise to have an attorney represent you. The hearing process is often a complex legal process with specific requirements for court procedures.

For more information, contact our Cobb County workers’ comp attorney at Chester & Beller today.