Denied Workers’ Comp Claims

Columbus Ohio Denied Workers’ Compensation Claims 

Filing for workers’ compensation, in and of itself, can be a stressful experience.  Learning that your claim has been denied can magnify this stress.  It is surprising and disappointing to receive a letter from an employer’s workers’ compensation insurance or claims administrator that says that a claim is delayed or denied.  Unfortunately, it is not uncommon for insurance carriers or claims administrators to find a basis for denying that your injury occurred at the workplace, or that you were acting as an employee at the time of the injury.  The first thing to understand is that should such a hiccup in the process occur, it is not automatically the end of the workers’ compensation claim process.

Should an injured employee’s claim be denied, it is important that he or she understand possible reasons why the claim may have been denied, and what steps should be taken next.

Possible Reasons for Delay or Denial of Workers’ Compensation Claims

There are many reasons for delaying the determination.  A delay letter will explain the reason(s) as to why a claim was delayed, and what additional information is required for the adjuster to determine whether a claim will be admitted or denied.  Keep in mind, an adjusting agency is required to respond to a claim in a timely manner.  Therefore it can be easier for them to send a delay letter rather than conduct an investigation.

Workers’ compensation claims can be denied for many reasons.  One common reason for denial is that the claim was not reported or filed within a proper timeframe.  Employees are required to report a claim immediately, sometimes within only a few days of the workplace injury.  The employer must then inform their workers’ compensation insurance carrier, or the state, just as quickly.

Another common reason for denial of a workers’ compensation claim is the employer disputing the claim.  This can occur because the employer says that the injury is not covered; disputes the location of the injury (for example, they may claim that it happened while the employee was at home); or disputes that the injury is a result of the accident.  If an employer disputes the claim, the employee will need to gather additional evidence to support the claim, such as witness statements, incident reports, or statements for a doctor attributing the injury to an occurrence at work.

What to Do When a Claim Has Been Denied

The first step to take after a workers’ compensation claim has been denied is to read the denial letter carefully.  The letter may also describe how to appeal the denial of the claim, and provide important deadlines that must be followed.

After carefully reading the denial letter, an employee should consider contacting the employer or its workers’ compensation insurance carrier to discuss the denial.  If the denial was due to a missing document, misspelled name, or similar issue, the mistake could be cleared up easily.  However if the employer still refuses to allow the claim, it may be time to appeal the denial.

Should an appeal be necessary, it is important to contact a workers’ compensation attorney to understand your rights and duties during the appeal process.

Schedule a Free Consultation with Columbus Workers’ Compensation Lawyers

The workers’ compensation appeal process can be difficult without the help of an attorney.  The lawyers of Agee Clymer Laret and Mitchell are available for a free consultation for any injured worker wanting to appeal a denied claim for workers’ compensation.

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    Employment law covers hiring, firing, workplace policies, and benefits. Recognizing this makes plain how a Cleveland employment lawyer could help an employee or an employer in any given negotiation or lawsuit. An employment lawyer’s knowledge of federal and state laws and practices regarding discrimination, rights, and contracting often proves invaluable when issues between workers and management arise.

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  • Injuries Not Covered Under Workers’ Compensation

    Workers’ compensation exists to help individual who get injured or fall ill on the job. Therefore, only someone hurt or sickened at work or while engaged in activities directly related to fulfilling the duties of their job can claim workers’ comp benefits. The health problem must be significantly disabling, meaning the person has to stop working or accept a lower-paying position for several months. Also, the problem can affect any part of the person’s body or physical functioning. Losing a finger, going deaf or blind, having a heart attack, and developing a permanent lung disease are all examples of injuries and illnesses eligible for workers’ comp.


    Location Matters

    Distinguishing what counts as a work-related activity sometimes requires going to court. Clarifying the issue somewhat, general rules that have developed over time that indicate that driving a company vehicle during business hours qualifies, but taking your own car to the office in the morning before the start of the business day does not. Similarly, falling while putting on a safety suit in the factory locker room could be what lawyers call compensable, but tripping while dressing for work at home would not be. Parking lot injuries are whole separate category of worker’s comp case law.

    Questions about whether an offsite or near-site incident could make you eligible for applying to receive payments from the Ohio workers’ compensation program are best referred to a Cleveland workers’ comp attorney before going through the lengthy process of applying for benefits.


    Cause Matters

    The state-run program to cover injured and ill workers’ medical bills and temporary disability expenses does have a list of circumstances that automatically disqualify applications. It looks like this:

    • Self-inflicted injuries
    • Injuries suffered with under the influence of alcohol or drugs
    • Injuries suffered while engaging in clearly illegal activities, including trespassing or violating environmental laws
    • Injuries suffered while fighting with co-workers
    • Injuries suffered while purposely ignoring safety rules, which includes engaging in horseplay
    • Worsening of a preexisting disease even when workplace exposures cause flare-ups that make doing one’s job impossible
    • Strictly mental difficulties such as stress

    This list of workers’ compensation exclusions leave space for interpretation, especially since employers may attempt to convince the program administrators who investigate workers’ comp applications that a hurt or sick worker caused their own health problems. A skilled and caring workers’ comp lawyer in Cleveland, Cleveland, Ohio, can help a client gather and present evidence to counter such claims.


    Options Exist When Workers’ Comp Doesn’t

    Speaking with an Agee Clymer Mitchell and Portman personal injury attorney could help you explore options other than workers’ compensation. While filing and succeeding with civil lawsuits against one’s employer has become increasingly difficult in Ohio, evidence of reckless indifference to employees’ health and safety remains actionable. Another possibility could be pursuing a defective or dangerous product claim against the manufacturer of a tool or device that inflicted an injury. That tactic can succeed when a machine malfunctions, a hand tool breaks, or a walkway railing or ladder collapses.

    To discuss workers’ comp and related issues at no cost, call Agee Clymer Mitchell and Portman at (800) 678-3318 or schedule an appointment online.

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I want to thank you for representing me with my Worker’s Compensation claim. Obviously, I am very happy with the decision of Hearing Officer. I know that my employer can still appeal the decision but I hope that will not be the case. Regardless, I...

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