Accepted v. Denied Claims-Workers’ Compensation

I typically get a lot of clients who are confused when it comes to workers’ compensation claims and what it means if the claim is accepted or if it’s denied. This may sound like an easy distinction, but in the world of workers’ compensation, it is not always abundantly clear. This article will help try to clear up any confusion.

The breakdown of events for a work injury will typically occur as follows: An injury occurs at the workplace, the injured worker notifies the employer and fills out a first report of injury. The report is then given to the workers’ compensation insurer and they begin to investigate the file to determine when they will approve it or not. The employee will often be required to fill out a medical authorization for the employer to get medical records and properly investigate the claim. I often get injured workers that are hesitant to sign the authorization, but a refusal to sign the authorization will likely result in a denial of the claim for failure to cooperate.

If the insurer investigates the claim and accepts liability, the injured worker will receive a Notice of Determination of Primary Liability. This form will also have the average weekly wage and compensation rate on the form. It is important to make sure this information looks accurate as this is what will be paid in the event the injury requires the employee to miss time from work. Remember, the compensation rate is 2/3’s of the average weekly wage (I’ve explained in greater detail on wage loss benefits are paid in a previous article). With the claim being accepted, all medical treatment related to the injury will be paid by the workers’ compensation insurer. So it’s important to note that since the claim is being accepted, the injured worker will be assigned a claims adjuster and claim number. It’s important to keep this information handy, as you will need it when you visit the doctor so the bills will be processed to the workers’ compensation insurer and not your personal insurance. If the injury precludes the employee from returning to their pre-injury job for an extended period of time-a QRC will be assigned to your file to help the injured worker with vocational assistance (QRC is also further explained in another article).

If the claim is denied, the breakdown of events will be similar at the beginning as approved claims. However, the Notice of Determination of Primary Liability will indicate that the claim is being denied and will give a reason for the denial. It is at this point where the injured worker often consults with an attorney to determine whether or not they believe the claim was improperly denied. If the attorney accepts the case, we will investigate the file by getting medical records and getting detailed information surrounding the injury from the employee and file a Claim Petition on their behalf. This document begins the litigation process in a workers’ compensation claim, which results in either a formal hearing or often times a settlement between the parties prior to a hearing.

A lot of confusion with my clients surrounds claims that are initially accepted by the workers compensation insurer, but then certain benefits are discontinued sometime after the initial acceptance. These benefits may be wage loss benefits, medical benefits, or vocational assistance benefits. What will typically occur in these instances is that the injured worker will get a notice from their adjuster that they are scheduling them for an Independent Medical Examination with a doctor assigned by the insurer. A report will be generated from the medical visit, which often marks the time when certain benefits are denied going forward. This is another time where the injured worker seeks out an attorney to understand what their rights are. It’s important to understand that these notices that cut off benefits that were previously being accepted require a prompt response from the employee if they are contesting the cutoff. As such, seek out a workers’ compensation attorney immediately if you receive one of these notices.

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