While workers' compensation offers a no-fault benefit option for employees injured on the job, many employees will have to apply several times before their workers’ compensation benefits are accepted. An employee may have to appeal a denial of claim multiple times in order to continue receiving benefits. Whether your claim for workers' comp has been denied for the first or the fifth time, it is important to know what options are available.
Reasons Why a Workers' Compensation Claim May Be Denied
The first thing you need to do is determine the reason that your claim was denied. By law, the denial letter should contain an explanation of why you are not eligible for benefits. Some denials are simply due to late filing or administrative errors, while others will require additional documentation in order to prove eligibility.
For example, your employer may attempt to deny you access to workers' compensation benefits for a variety of reasons, such as:
- Your employer believes the accident happened outside of work
- Your injury was caused by your own horseplay or intoxication on the job
- Your injury was of a nature that it could just as easily have happened off the job (such as a heart attack or stroke) and does not qualify for workers’ compensation
- You did not receive any medical treatment related to the accident
- You did not receive immediate medical treatment or see a doctor in the days following your injury
- You have a history of filing workers’ compensation claims
- You failed to disclose to your employer that you suffered a significant prior injury
- There is not enough evidence to prove that injury is work-related
Once you know the reason why the claim is denied, you can begin to appeal the decision. In some cases, a denial can be resolved without an appeal, such as if the denial is based on a typo or clerical error. However, if the application and evidence presented are factually correct, you may have to file an appeal with the Illinois Workers' Compensation Commission (IWCC).
Appealing a Workers' Compensation Claim Denial
If your workers' compensation claim has been denied, the first thing you should do is consult with a qualified workers' compensation attorney. An attorney can be invaluable in asserting your claim, acting in your best interests, and answering your questions throughout the progression of your case.
Your attorney can also help guide you through the appeals process, including:
- Filing the appeal. Appeals begin with the filing of a form called the application for adjustment of claim. There are strict deadlines for filing this form, and your attorney can ensure that it is completed quickly and accurately.
- Gathering documentation. Your attorney will assist you in gathering any evidence that can help secure your benefits, including medical records, timesheets, video footage of the accident, and anything else that may help your appeal.
- Requesting a hearing. Once the application for adjustment of claim has been filed, the IWCC will assign an arbitrator to your case. Once you have reached maximum medical improvement, gathered your evidence, and have prepared your case, you may request an arbitration hearing date.
- Attending an arbitration hearing. An arbitration hearing is similar to a trial. An arbitrator will listen as both sides will present evidence to prove or disprove benefit eligibility, and then the arbitrator will issue a decision.
- Filing an administrative appeal. If the arbitrator does not agree with your claim, you can request an administrative appeal. This is done by filing two copies of a petition for review with the IWCC within 30 days of the arbitrator’s decision, along with a letter explaining your objections to the decision. A panel of three commissioners will convene to review the evidence presented at your arbitration hearing and the written arguments submitted by you and the insurance company. The panel will then issue a decision within 60 days.
- Proceeding to judicial appeal. If the IWCC panel does not grant you benefits, you may need to take your appeal through the state court system.
If your workers’ compensation benefits have been denied, we can advise you on your next steps at no cost to you. Contact Tapella & Eberspacher today at (217) 394-5885 or fill out our online contact form to schedule your free consultation.