Thursday, October 6, 2016

Workers' Compensation Claims: Complications and Denials



Five common issues that injured workers encounter:
Claim was denied.
Employers and insurance companies often deny workers’ compensation claims before they ever really get started. The exact number of how many claims are filed versus how many claims are denied is unavailable, since the Florida department in charge of overseeing claims doesn’t publish data in this area.
One must remember that insurance companies are a business; a business’s goal is to make a profit. This could obviously not be done if everyone’s claim was approved. This does not mean that only invalid claims are denied. Often, perfectly legitimate injury claims are denied every day, with the insurance company and the employer hoping the injured won’t bother to dispute it.
Insurance companies are also under pressure from employers who want to keep their premium costs as low as possible. Because of this, insurance companies carefully scrutinize claims to find ones they can deny or reduce benefits to. The less claims an insurance company pays out, the lower they can keep their premiums.
Claim process is being dragged out or staled.
A worker’s compensation claim can take a long time to go through, especially if something about the claim is contested. If a lawsuit is filed contesting the claim, then pre-hearing discovery and depositions must be collected and carried out; this can be time consuming. One may also need to seek additional medical opinions, either because they don’t agree with an opinion that was given or because the insurance company requested one for a similar, albeit, converse reason. Someone may also need to seek additional opinions to establish or contest something called, Maximum Medical Improvement (MMI). All these things can make a seemingly simple process take much longer than expected.
The amount received doesn’t seem like enough.
One of the biggest complaints regards the amount that someone receives from a settlement or a judge’s order. This is because workers’ compensation claims are limited to partial wage reimbursement and medical bills. In some extreme cases, compensation may be awarded for loss of limbs, permanent debilitation, and other cases of severe loss. Workers' compensation laws do not normally allow compensation for pain and suffering. This can often make the monetary figure feel insignificant, since it often doesn’t even cover the entire amount of out-of-pocket expenses, much less compensation for everything an injured party has to go through.
Employee was fired after filing a claim.
It is illegal for an employer to terminate a worker because they filed a workers' compensation claim. The situation becomes less clear when a doctor has certified a worker as able to return to work and the injured party disagrees with that doctor's opinion. Once an injured worker is medically cleared by a doctor to return to work, and they refuse to do so, an employer does then have the right to terminate their employment.
Despite medical clearance, a claimant is still in pain.


This situation often arises when pain and medical conditions/diagnosis don’t match. For example, the doctor may diagnosis a patient with a minor back sprain that they claim will go away in a week or two. However, it has been a month and the patient is still in a high level of pain. Therefore, the doctor has cleared the patient to return to work, yet the patient finds even walking to be difficult. These situations are often the toughest to handle, but it is very possible to work it out in benefit of the injured.
Remember, pain is subjective, and therefore, cannot be measured definitively.
A doctor may diagnose an injured worker as having reached maximum medical improvement, but the worker may disagree. If someone does not agree with the MMI diagnosis or allotted recovery time, the best thing to do is seek a second medical opinion.
Filing a Complaint against the Insurance Carrier
If you have credible evidence that your claim was wrongly denied—fraud, administrative error, or another irregularity—you can file a complaint with the state of Florida. The form can be found here. When you file a complaint, it will go through a review process.
If you feel that you need to file a complaint with the insurance company, it is probably time to start thinking about hiring an attorney. Despite what your employer and their insurance company might tell you, an attorney can be very beneficial in helping to reverse a denied claim and recover much more than what a carrier will offer on their own.
Common Reasons Workers’ Compensation Claim are Denied
Failure to notify your employer of injury within time limit.
You should immediately—or as soon as reasonably possible—notify your supervisor when you are injured. Each state is different, but Florida requires that injury is reported to the employer no later than thirty (30) days. You can read the statute here. Technically, your claim doesn't begin until you report your injury to your employer.
Statute of limitations has ran out.
Reporting your injury is not the same as filing a workers’ compensation claim. The time in which you must actually file the complaint is known as a ‘statutory limit period.’ Missing this filing time window is grounds for denying your claim.
In Florida, the statute of limitations requires that a claim must be filed within two (2) years of the date of accident.
Your injury didn’t occur at work.
In order to be eligible for coverage by your employer’s workers’ comp insurance, your injury must have occurred while performing your work duties on your employer's premises. You will also be covered if it occurred off-site while performing duties assigned to you by your employer or supervisor.
If your injury occurs before or after normal work hours, even if you are technically doing something to complete a work task, your injury may not be covered. This is why most big companies are extremely strict  about not working ‘off the clock.’
Your injury occurred while you were under the influence of a substance.
If you were injured while under the influence of alcohol or illegal narcotics, your claim will most likely be denied. It does not matter how hard of a worker you are, how long you've been with the company, or what type of work you were doing.
Some people think they are safe from this provision, because they would never go to work drunk or high. However, blood tests are performed after an injury, which can show alcohol in the blood even from the night before. This is often grounds to deny a claim. If proof exists that even a small amount is still in your system, your claim will probably be denied. This is also true for some up-to-date, doctor prescribed medications. For example, if you were taking a prescribed narcotic painkiller or anxiety medication for completely unrelated reasons, and the insurance company can prove they were in your system at the time of the injury, it is likely your claim will be denied.
Your employer has decided to dispute your injury.
As the injured party, you are responsible for proving that you are injured. An employer does not have to prove that you are not injured. This is called the burden of proof. An employer may dispute the claim for any number of reasons—by claiming that your injury was pre-existing, it occurred outside of work or while performing a non-work related task, or that you are faking your injury.
The injury or condition you suffered isn’t covered.
A good example of this psychiatric injuries. Workers’ compensation claims that are based on mental health issue are almost always initially denied. This is because it is difficult to prove that the mental health issue occurred as a result of your work. To be covered, you must be able to link your mental health issues to a specific, work-related event. For example, if you are filing a claim for anxiety after a near-death situation at work, you would have to prove that one is related to the other. Florida does cover psychiatric injuries from specific events, such as post-traumatic stress disorder (PTSD). Even conditions arising over time, such as depression and severe anxiety, may be covered, if it can be proven that they are directly related to work. This requires precise and convincing medical evidence from a licensed psychiatrist. Even then, it is likely to be disputed, at least initially.
Your employer doesn’t consider your injury to be serious.
As mentioned earlier, there is often a discrepancy between what someone feels and what their diagnosis is. Everyone is different. You may think that your injury is debilitating, but your employer or their insurance company may not consider it to be all that serious.
In order to technically qualify for workers’ compensation, your injury must limit or fully prohibit you from completing your job duties. This, like all the other things related to a personal injury case, will ultimately be settled by a doctor’s—ideally multiple doctors’—opinion. It is these issues that make it imperative to have an experienced workers’ compensation attorney on your side. They have seen all the tricks of denial and know how to handle them. They are also often familiar with credible doctors who will not give a wrong diagnosis just to help out an insurance company.
How to Appeal a Denied Workers’ Compensation Claim
If your claim is initially denied, which is very common, you do have options. Although it is frustrating, you have the right to dispute the claim’s denial. Once the insurance carrier decides to deny your claim, they will send you a denial letter with an explanation of your workers' compensation insurance coverage, your rights to appeal, and the deadline for filing your appeal.
An Experienced Workers’ Comp Attorney
The initial filing of most workers' compensation claims can be handled without an attorney. When your claim is being unnecessarily delayed or has been unfairly denied, it is probably time to retain an attorney.
Dolman Law Group represents injured workers in the Clearwater-Tampa Bay area on a regular basis. We have a proven track record with real, credible results. Before you hire any attorney, you should research their reputation. The best places to do this on attorney ranking website Avvo.com, through Superlawyers.com, the Florida Bar Association, and of course, Google Reviews.
We welcome this kind of scrutiny. We are sure we can help you, and we want you to be sure you made the right decision. Once you retain us, you will be sure you did.
Every client receives their attorney’s personal cell phone number and email address. This way, we can personally serve you and solve your workers’ compensation case on an individual level.
We understand that filing a claim with an insurance company is often difficult and frustrating. We are here to help, every step of the way.
Contact us today for a free consultation at (727) 451-6900.