When you suffer an injury at work, the worries and concerns immediately start building. When will you be able to return to your job? How will you cover medical expenses? What if your injury prevents you from earning an income to support yourself and your family? How can you work towards recovery while agonizing over finances? These questions become even more pressing if you find out workers comp denied treatment. Can they really do this? Why? And what can you do if you are denied benefits?
What Workers Compensation Should Cover
Most workers in the state of Florida are covered by workers compensation insurance via their employers. (Federal employees have a separate program, and there are certain exemptions for very small businesses.) When you are injured, your benefits are intended to cover:
- Lost wages due to your injury (usually ⅔ of your regular wage)
- Doctor’s visits
- Diagnostic testing (e.g., x-rays, MRIs)
- Physical therapy
- Referrals to specialists
Under the law, if your employer must carry workers comp insurance, you are covered – regardless of fault (unless you were intoxicated or under the influence of drugs).
If you are entitled to this protection, why would your claim be denied?
Common Workers Compensation Denial Reasons
Your workers compensation benefits may be denied because:
- You did not report your injury in a timely manner. If you are injured at work or have become ill due to work-related reasons, you should report it to your employer as soon as you can, preferably immediately. In Florida, as in many states, you have 30 days to report. If you do not, your claim can be denied.
- The injury wasn’t related to work. To receive workers compensation, your injury/illness must be caused at work or while completing work-related tasks. This can get tricky; for instance, if the pressure at work is so intense that you suffer a heart attack, you may be able to receive benefits. This is why it is so critical that you consult with an experienced workers comp lawyer as soon as possible.
- You didn’t seek medical treatment. It is essential that you receive medical care when you are injured at work. Your safety and well-being is of primary importance. And you need to take this step in order to receive benefits. If your injury requires emergency treatment, you do not need to see an approved provider. If it is not, you must use an approved physician. Be sure to ask your employer which providers are acceptable.
- You were under the influence of drugs or alcohol. As mentioned, this will result in a claim denial. After a workplace accident, many employers require a drug test. If your results are positive, you will not be eligible for workers comp.
- There are no eyewitnesses. It is possible for your employer to deny your claim because there are no eyewitnesses or verifiable evidence of the accident/injury.
- There are discrepancies between your account of the accident and your medical documentation. If your employer or the workers comp insurance carrier deems that your medical records do not back up your account of the accident, they may deny your claim.
- Your employer disputes your claim. They may do this for a variety of reasons, from not having enough evidence to not wanting their premiums to increase.
Some of these reasons make sense. If an employee was under the influence of drugs or alcohol, for example, or if their medical records uncover a blatant untruth, of course employers should not bear the cost. However, claims are often denied for spurious reasons that put injured employees’ health – and finances – at risk.
Why Workers Comp Denied Treatment
You may also be denied treatment, which is unconscionable. Why would this happen?
- If your doctor requests approval for a certain test or procedure, the insurance company may say it’s unnecessary and deny the request.
- The insurance company does not respond to requests for treatment at all, effectively denying it.
If your doctor does not get approval, they likely will not perform the recommended treatment. After all, they won’t get paid.
The good news is that you can appeal a workers compensation denial.
Appealing a Workers Comp Denial
There is an established process for appealing a workers compensation denial:
- Conference for Dispute Resolution. Contact the Bureau of Employee Assistance and Ombudsman. They may assign you an ombudsman (an official assigned to investigate your complaint) to review your case and assist you in the resolution conference.
- Petition for Benefits. If your resolution conference is not successful, you can file a petition for benefits. You do this with the Office of the Judges Compensation Claim and forward copies to your employer and their insurer. You must file within two years of your accident/illness and include detailed information about your claim and disagreement with the insurance company.
- Mediation. Upon filing your petition, an informal mediation conference will be scheduled within 130 days. If both you and the insurance company agree that the results will be binding, you may not appeal the decision.
- Workers Compensation Hearing. If mediation is not successful, and nonbinding, you can have a hearing in front of a workers comp judge.
- Appeal with the Florida District Court of Appeals, First District. If you disagree with the results of your hearing, you can appeal to this court.
This is a complex process, and you will need to provide documentation (e.g., medical records, communications with your employer and/or insurance company, etc.) in order to make a compelling case.
The experienced attorneys of the LaBovick Law Group have handled numerous workers’ compensation cases; we not only know the ins and outs of developing a strong case, we understand how essential these benefits are to you as you recover from your work-related injury or illness. We have a long track record of fighting for our clients in the face of aggressive insurance companies with deep pockets. We will not be intimidated when it comes to protecting your rights.
If workers comp denied treatment or benefits, please contact us today. We can help.