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Denied Workers’ Compensation Claims

Workers’ Compensation claims are most often paid, workers recover, and they receive the benefits to which they are entitled. Unfortunately, insurance companies and employers can get in the way of the process. When injured workers do not know what to do, they must reach out to Mount Laurel Workers’ Compensation lawyers who will review their case and provide guidance.

Mount Laurel Workers’ Compensation Lawyers

Because Workers’ Compensation claims can be confusing, it is important to reach out to a lawyer as soon as the process begins. Some workers know that they will have a hard time filing a claim, reporting accidents, and more. There are times when the worker is denied by the insurance company, or workers may be presented with options that they do not understand. Bring all relevant information regarding a work-related injury to a lawyer today and review what can be done. The Workers’ Compensation process is not complete until an experienced lawyer has litigated the case as much as they possibly can.

Is Workers’ Compensation a No-Fault System?

Workers’ Compensation is a no-fault system that does not assign blame to either the employer or the employee. The employer avoids all liability for accidents or work-related injuries in exchange for coverage. The employee cannot be blamed for their accident or injuries as well. Employees can be denied coverage only if they have broken the law or engaged in horseplay or avoidance of their job duties that resulted in an accident. These exceptions must be accompanied by solid evidence, and a lawyer should be consulted. When workers believe that they were hurt by another employee’s negligence, they should explain to their lawyer how the accident occurred.

Reach out to a Workers’ Compensation lawyer when it is clear that a claim is not treated as a no-fault claim. Do not say anything more to the employer. Do not call the insurance company to complain, and do not threaten a lawsuit without substantial evidence to back up such claims. These entities will record or notate everything that is said. Do not give them anything they can use to invalidate a claim.

Can a Workers’ Compensation Claim be Denied?

Workers can be denied coverage at any time. There are a few roadblocks that employees may face when they require coverage. Managers or supervisors might not accept injury reports, or those reports may never be sent to the insurance provider. In more troubling cases, companies that should provide coverage do not carry the appropriate insurance. Aside from the fact that the worker should be covered, the business will be cited by the state for its negligence in not carrying the appropriate coverage.

Mount Laurel Workers’ Compensation Lawyers

The insurance company might deny claims because it believes the injury did not occur at work or that the worker does not qualify for one reason or another. Workers’ Compensation is a no-fault system, and the insurance company cannot deny coverage unless the injured worker was breaking the law. The insurance company may also wrongly interpret the claim. Additionally, the manager or supervisor who processes the claim may not write the claim appropriately. These claims might get lost in a slew of paperwork, or they may be submitted to the wrong people. Tracking the paper trail of a claim is easy, and the claim can be filed after a lawyer gets involved.

In some cases, the insurance company truly believes it has made the right decision. The employee cannot call and argue this point with the insurance company as they do not have access to the people who make the decisions. Moreover, the insurance company will record these calls and try to use anything that was said against the employee.

Reach out to a Workers’ Compensation lawyer when it is clear that there is a glitch in the reporting process. Employees cannot force their employers to accept reports or send claims to the insurance company. Working with a lawyer gives the worker more options. A lawyer knows how to talk to all these stakeholders, and they will help prevent confusion for the injured worker.

Who Denies Workers’ Compensation Claims?

When a claim is denied, the insurance company is often at the center of the case. The insurance company uses certain metrics to determine when claims will be approved. If the insurance company mishandles the claim, the problem can be corrected after a negotiation with a lawyer. When employers attempt to deny these claims, they are operating outside of their capacity. Employers cannot tell an eligible employee that they are not covered. The employer must also advise employees of their rights.

Someone who works for the company as an independent contractor is not covered under Workers’ Compensation, and they should be made aware of this. These employees are eligible to file a personal injury lawsuit if the employer was negligent. Insurance companies might also reach out to a covered employee looking to settle as quickly as possible. Injured employees should not speak to anyone without a lawyer present. Do not agree to anything without speaking to a lawyer as this may result in a de facto settlement that is difficult to undo.

What is an Independent Medical Exam?

An independent medical exam (IME) is often ordered by an insurance company to prove that an injured employee is capable of going back to work. The IME is arranged by the insurance company and often features a doctor it has chosen. This is often a backhanded way of denying a claim and forcing someone to go back to work. Instead of simply attending one of these exams, ask a lawyer to negotiate a time, place, and physician for the exam. A lawyer can prepare injured workers for the IME, and they will explain what to say or not say. Additionally, this medical exam is the only time that the patient can explain the severity of their injuries and the ramifications thereof. Bring all medical records and documentation that is available so that the doctor has a clear picture of how deeply this injury or accident has affected the employee and their family.

Remember that anything said during one of these exams could be used against the employee. The doctor needs to see how much this injury has affected the patient to the point where they simply cannot clear them for work. These exams can also be used to show that the victim cannot recover any more than they have. If this is the case, the doctor will note that they have reached maximum recovery and must be placed on some form of permanent disability. This exam might also be used to determine the level of partial disability, the percentage of disability for all injured limbs, and to write a formal letter explaining their findings.

While these exams can be ordered at any time, they are often used by insurance companies to deny permanent disability coverage. Because a worker in New Jersey can spend several years on temporary disability, it is important to be prepared for these exams as they will eventually occur.

Can I Choose My Own Doctor?

In New Jersey, employees can only choose their doctor if they need emergency care. Workers’ Compensation will pay for emergency care because this is often a life-or-death situation. After the employee has been stabilized, the employer or insurance company may choose an in-network doctor or medical facility for further care.

Mount Laurel Workers’ Compensation Lawyers

While the employee does not have the power to choose their doctor, some employers offer a list of doctors to choose from. If the employer or insurance company insists on choosing the doctor, they might delay treatment with testing, or it may be impossible to get an appointment with that doctor. Some doctors might tell employees there is nothing more they can do, and they will need to manage their pain while returning to work.

When this is the case, the employee must reach out to a lawyer who will request a new doctor or make light of issues that arose because the doctor was not responsive or provided inadequate care. At times, the insurance company is unaware of these happenings, and that is why a formal inquiry by a lawyer should be initiated.

How Should I Respond to a Denied Workers’ Compensation Claim?

When a Workers’ Compensation claim is denied, employees should not lash out or blame the employer. In most cases, the claim is out of the employer’s hands and handled by the insurance company. When calling an insurance company for more assistance, the customer service agent who answers the phone has absolutely no control over the claim. Refer the claim to a lawyer who can review the denial. The denial typically comes with a letter explaining what has occurred. Some denials might cite a lack of information, or the denial letter may misclassify the employee’s actions.

Mount Laurel Workers’ Compensation Lawyers

Threatening the insurance company or the employer only serves to weaken the victim’s position. Anything that is said could be repeated in court or a deposition. Victims who are extremely angry might say things they regret or that they would not want repeated in front of a judge or jury. Refer to a lawyer immediately to cut contact with the employer or insurance company. Moreover, a lawyer can send a formal letter that will cause either the employer or the insurance company to take the claim seriously.

Can I Appeal Denied Workers’ Compensation Claims?

Denied Workers’ Compensation claims can be appealed by a lawyer. Do not attempt to file the claim again as this may muddle or delay the process. The insurance company is aware that it denied the claim, and it often expects a lawyer to come calling. Because this is the case, the insurance company has lawyers ready to defend it from any issues arising from a denied claim.

When a lawyer appeals a denied Workers’ Compensation claim, they will collect evidence proving that their client should be covered. The insurance company may attempt to speak to the employee about the accident rather than the lawyer. The insurance company may also attempt to settle for very little money and avoid litigation. Allow a lawyer to handle the appeal and subsequent negotiation. There are settlement options available for both parties, but an injured worker who is focused on recovery should not be forced to negotiate alone.

What Evidence Does My Lawyer Need?

Lawyers need as much evidence as possible when fighting a claim denial. Evidence collected by the employee or their co-workers might include:

  • The date and time of the accident
  • A picture or video of the accident scene
  • Possible security footage of the accident
  • Eyewitness testimony about the circumstances leading up to the accident
  • The date and time an injury report was made
  • The name of the supervisor who took the injury report
  • Medical records related to emergency medical care

A lawyer will initiate their own investigation once they accepted the case. They may need to know if faulty tools were involved or if another employee caused the accident. A lawyer must also investigate the employer’s delayed response to the accident, a refusal to accept insurance claims or injury reports, and any malfeasance on the part of the insurance company. As the case unfolds, lawyers may also ask for income statements, more medical records, or speak to medical experts.

Can I Settle a Workers’ Compensation Claim?

Mount Laurel Workers’ Compensation Lawyers

Settlements are possible outside of court. Most workers who file claims believe that they will receive small payments every week or month. They may also believe that all their medical bills should be sent to the insurance provider. Settlements can close a claim, and the state of New Jersey allows for two different types of settlement:

  • Section 20 Settlements: A lump sum is paid after there are questions about the circumstances of the accident
  • Section 22 Settlements: Also known as Order Approving Settlements that use a state-mandated payment schedule

When a Workers’ Compensation lawyer reaches a Section 20 settlement with the insurance company, both sides have questions about the circumstances of the accident. However, neither side can prove their case definitively. In lieu of spending years in court trying to litigate the case, the two sides can reach a Section 20 settlement. The insurance company pays a lump sum to the employee, the employer admits no wrongdoing, and the case can be reexamined within two years at the request of either party.

A Section 22 settlement, also called an Order Approving Settlement, pays a certain percentage of disability based on injuries to the worker. For example, an employee who severely injured their elbow will receive a percentage of the award allowed under New Jersey law for injured elbows or arms.

Each injury will be calculated in the same way, and a lump sum will be paid. The case cannot be reopened, the insurance company closes the claim, and the employer admits no wrongdoing. When the case has already gone to court, a judge must approve these settlements so that the case can be closed. If the settlement can be reached before going to trial, a judge need not get involved.

Additionally, the family of a deceased worker may prefer to settle for death benefits instead of receiving monthly payments. While these monthly payments may last for many years, a young parent may prefer to receive a lump sum that allows them to move on immediately after their spouse’s death. The situation may be complicated further if the children or spouse do not live with the deceased.

Walking away from a case with a settlement may be the fastest way for the family to pay their bills, handle medical debt, and begin the rehabilitation process. The settlement also relieves the family of the burden of a lengthy legal process and repeated phone calls or letters from the insurance company or employer.

What is Appropriate Workers’ Compensation Coverage?

Litigation regarding a claim may result in an order or settlement that provides appropriate coverage for the worker. Appropriate coverage begins with either temporary total or temporary partial disability. The employee’s salary is paid at 70 percent of their current rate, medical expenses are covered by insurance, and the worker is allowed to remain on temporary disability for weeks, months, or even years before a permanent award is provided.

Permanent partial disability indicates that the victim is disabled but may be able to find gainful employment. They are offered vocational rehabilitation, and the difference in salary is paid via Workers’ Compensation coverage. Permanent total disability is paid when the victim cannot work at all and is totally disabled. These awards can last a lifetime, but they may also be settled so that both the insurance company and victim can move on.

Specific injury benefits may be provided for a catastrophic injury, such as an amputation, loss of sight or hearing, or loss of use of a limb. Depending on the severity of the injuries and the complexity of the case, these benefits may be paid in a lump sum settlement instead of through traditional monthly payments.

Mount Laurel Workers’ Compensation Lawyers

Death benefits are also available, and the insurance company should provide those benefits to the spouse, children, or dependents of the deceased worker. These benefits should be provided if the worker died in an accident or if they passed away due to their injuries after the fact. The family of a deceased worker may not realize that death benefits are provided, or they may be denied by the insurance company. Because the family does not have direct knowledge of the accident or their deceased loved one’s rights, they may not know how to proceed.

Speak to a lawyer when appropriate coverage is required. Employees typically do not think of all the disability payments they can receive, and they may not know what they are entitled to.

Mount Laurel Workers’ Compensation Lawyers at Kotlar, Hernandez & Cohen, LLC Help Injured Workers with Denied Claims

When your Workers’ Compensation claim has been denied, reach out to the Mount Laurel Workers’ Compensation lawyers at Kotlar, Hernandez & Cohen, LLC for assistance with necessary lawsuits and appeals. Call us today at 856-751-7676 or contact us online for a free consultation. Located in Mount Laurel, Cherry Hill, Trenton, and Vineland, New Jersey, as well as Trevose, Pennsylvania, we assist injured workers throughout Pennsylvania and New Jersey.

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856-751-7676 16000 Commerce Parkway
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Mt Laurel Township, NJ 08054 Monday - Friday | 8am - 5pm

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