Have a Claim Denied?
It is disappointing to receive a letter from your employer’s workers’ compensation insurance or claims administrator that says that your workers compensation claim is “delayed,” or worse, “denied.” Unfortunately, it is not uncommon for insurance carriers or claims administrators to find some basis for denying that your injury occurred at work, or even that you are actually an employee. The first thing you need to know is that this is not the end of the workers compensation claim process. If you receive a denial letter and you do nothing it could result in losing your right to pursue your claim. However, you do have the right to challenge the insurance decision and there is a process for pursuing that challenge. The legal process for challenging the decision by a claims administrator or adjuster to deny a claim begins with the filing of an “Application for Adjudication of Claim,” commonly referred to as an “Application.” Upon the filing of the Application, you become the “Applicant.” You can file the application yourself, but it is more common to obtain the assistance of an attorney.
There are many reasons for denying a workers’ compensation case and even more for delaying the determination. The “delay” letter will often tell you what information is necessary for the adjuster to determine whether your claim will be admitted or denied. It should state a reason such as, “I need to conduct an employer level investigation” or “I have no medical evidence that your injury is industrially related.” Since the adjusting agency is required to respond to your claim form promptly it is often easier to send out a delay letter than to conduct a real investigation.
The most disturbing trend is that an adjuster will deny a claim, “because there is no substantial medical evidence that proves your injury is industrial and you have not been evaluated by a Qualified Medical Examiner (QME)”, despite the fact that all the medical evidence from your doctor states that the injury is industrial. There is no legal basis to require an evaluation by a QME as the only grounds for admitting a work injury. Your treating doctor can diagnose a work injury. This seems to be a ploy to delay claims in hopes that you will give up and go away. It may violate the requirement to conduct a good-faith investigation. On the other hand, there are many situations, as discussed above, when a treating doctor does not clearly state that an injury occurred at work and clarification is necessary
For many reasons stated above as well as many more I would need to discuss with you regarding your personal situation, its my advice to seek legal counsel. At the Law offices of Christine Nelson we can provide you with a free consultation to better understand your case.