The workers’ compensation system is complicated, and although most claims go relatively smoothly, some valid claims get denied, for any number of reasons. Here are 6 explanations of why your workers’ compensation claim was denied:
1 – You Were Injured, But Not at Work
To be eligible for workers’ compensation benefits, a worker must have been injured while in the course and scope of their employment. Under workers’ compensation law, benefits are available to a worker who is hurt on the job, and no proof of fault needs to be made for benefits to be paid. All that needs to be established is that the injury occurred on the job and is connected somehow with the work the employee performed. But if the injury occurred while you were at lunch or running a personal errand, you most likely will not be eligible for workers’ compensation benefits. However, if you were on a work assignment outside the workplace, you could have a valid claim.
2 – You are an Independent Contractor Instead of an Employee
While employers are required to provide workers’ compensation benefits to employees, no such requirement exists for independent contractors. Generally, an employer-employee relationship exists if a worker performs services that can be legally controlled by an employer, such as what will be done and how it will be done, even if the worker is given freedom of action. An individual is an independent contractor if the person paying him has the right to control or direct the result of the work, but not how the work will be done. So if you are an independent contractor, you most likely aren’t covered by workers’ compensation law and entitled to benefits.
3 – You Didn’t File Your Claim in a Timely Manner
Under workers’ compensation law, an injured worker is required to file, in writing, a First Report of Injury within a specified time limit – as soon as possible and usually no later than 30 days after the incident, and failure to do so has different penalties, according to state law. The deadline for filing a workers’ compensation claim can vary from 30 days up to several years, again depending upon state law, and the time limit typically begins on the date of the accident and can be extended to accommodate payment of medical bills or lost wage benefits.
4 – You Weren’t Treated By a WC-Approved Medical Provider
According to workers’ compensation law, you don’t get to choose who provides treatment for your work-related injury – your employer and the insurance company do. You will receive a list of approved doctors that you can seek treatment from, and as long as you visit one of them, workers’ compensation will pay for your medical treatment. Unfortunately, many of these doctors devote their entire practices to performing Independent Medical Examinations for workers’ compensation carriers, and they often downplay your injuries, resulting in decreased benefits for you. If you did not receive any medical treatment for your injury and consequently have no medical records to document your claim, it will most likely be denied because you have no proof.
5 – There Were No Witnesses to Your Injury
Because fraudulent workers’ compensation claims have become relatively common, employers and insurers are usually somewhat wary about a workers’ compensation claim involving an injury that no one witnessed, which is a great disadvantage to those who work alone. If you were injured at work but no one witnessed it, there is nothing you can do about that, but you should immediately report the injury to your co-workers and supervisor, and make sure your paperwork accurately reflects how the accident occurred.
6 – You Didn’t Have a Workers’ Compensation Attorney
While you’re not required to retain an attorney to file a workers’ compensation claim, having one will dramatically increase the chances that your claim will be successful. An experienced workers’ compensation lawyer will guide you through the process, help you fill out the required paperwork, and recommend the documents that you will need to prove your claim.
Even if your claim has been denied, it’s not too late to contact a workers’ compensation attorney begin the workers’ compensation appeals process. For expert legal advice in workers’ compensation matters, contact DDB Law online or call 888-648-5999 to schedule your free initial consultation today.
Attorneys for a 42-year-old Connecticut man recently made the case for legal representation in a workers’ compensation matter when they obtained a $105,000 settlement for the food delivery employee, after an initial demand of $177,500 and a settlement offer of $95,000 from the insurance company.
Workers’ compensation was established to protect both the employer and the employee and to eliminate the need for litigation, but injured employees need to understand that a workers’ compensation attorney will not only protect their legal rights, but could also help them recover a more substantial settlement than what might be determined by the workers’ compensation system alone.
A worker who was injured on the job will typically file a workers’ compensation case without legal representation, particularly if their injuries are minor and temporary in nature, although there are times when it might be in the employee’s best interests to seek legal representation. But before they do so, it is important to understand the costs involved when retaining a workers’ compensation attorney.
Legal Fees in Workers’ Compensation Cases
When an injured worker hires an attorney to represent him in his workers’ compensation case, the lawyer will usually take the case on a contingency basis, meaning that the worker won’t be required to pay anything out of pocket at the onset of the case. Instead, the attorney will receive a percentage of the settlement, the amount depending upon state laws and the complexity of the case.
By eliminating the need to pay a large upfront retainer, such contingency fee arrangements allow all injured workers, including those with limited financial resources, to obtain legal representation. Contingency fee arrangements also provide an incentive for workers’ compensation attorneys to pursue maximum benefits for their clients. Generally, a workers’ compensation case that settles prior to an administrative hearing will require a lower percentage fee than one that requires a hearing or a trial in circuit court.
Workers’ Compensation Regulated by the States
State laws regulate the fees attorneys may charge in workers’ compensation cases, and these regulations vary from state to state. States often cap the amount an attorney can charge and also require that fees be approved by the workers compensation judge or appeals board before the attorney is paid. These laws vary substantially:
- A California workers’ compensation judge is free to approve a fee of between nine and 15 percent, depending on the complexity of the case.
- Florida workers’ compensation attorney fees are set at 20 percent of the first $5,000 of workers’ compensation benefits, 15 percent for the next $5,000, and five to 10 percent of the remainder, depending upon the time the attorney spent on the case.
- In Texas, an attorney is paid by the employer’s workers’ compensation insurance carrier, the percentage is are determined according to the attorney’s time and expenses and must be approved by the Division of Workers’ Compensation. Once the attorney’s fees are approved, the insurance carrier is ordered to deduct the fee amount from the injured worker’s benefits, up to 25 percent of the recovery amount.
Many states prohibit attorneys from charging fees for obtaining routine benefits for their clients, such as compensation for undisputed medical bills and lost wages, but may allow attorneys to petition the judge to order the employer or insurer to pay additional fees in certain circumstances, such as when benefits have been unnecessarily delayed or denied after they have been awarded. Percentage caps do not usually apply to these sanctions or penalties because they aren’t considered part of the injured worker’s compensation award.
Other Out-of-Pocket Costs
In addition to attorney fees, injured workers may be required to pay other out-of-pocket costs for:
- Court filing fees
- Copies of medical records and billings
- Fees for independent medical examinations
- Deposition costs
- Attorney travel expenses
- Postage and copying fees
These costs are typically not covered by the standard contingency fee agreement, and most law firms will cover these expenses as they arise, but the client will need to reimburse the firm for these costs if they are granted an award.
If you were injured on the job and have questions about retaining an attorney to represent you in a workers’ compensation claim, or need more details about the costs involved, contact DDB Law or call 888-648-5999 to schedule your free initial consultation today.
Many people do not understand the difference between a workers’ compensation case and a personal injury lawsuit. But a Florida employee who is injured on the job will need to be able to make the important distinctions that exist between the two.
Workers’ Compensation Basics
Workers compensation benefits are available to any worker who is hurt on the job, regardless of who, if anyone, was at fault for the injury. Florida workers’ compensation laws cover most but not all employees. Certain classes of employees are typically excluded, such as:
- Independent contractors
- Business owners
- Casual workers
- Employees of private homes, farmers and farmhands
- Railroad and maritime workers
- Those who are employed by companies with fewer than three to five employees
- Federal workers who are covered by federal workers’ compensation insurance
Workers’ compensation will typically pay for medical expenses, rehabilitation and some wage loss, but to obtain these benefits, your claim must be filed according to Florida workers’ compensation law:
- Report the accident to your employer as soon as possible, but no later than 30 days after it occurred.
- Your employer is required to report your injury as soon as possible, no later than seven days after their knowledge.
- The insurance carrier must send you an information brochure within three days of receiving notice from the employer.
- You will need to seek treatment from a medical provider that is authorized by your employer or the insurance company.
- Florida workers compensation coverage will replace part of your lost wages if the doctor says you must not work for a certain period of time due to the injury or illness.
In a workers’ compensation claim, most injured workers will recover benefits in a timely manner, but for some, it may be necessary to file the claim with the Florida Division of Workers’ Compensation.
Personal Injury 101
Compensation isn’t limited to employees injured on the job. Anyone who is injured due to the carelessness or negligence of another may be eligible to bring a personal injury lawsuit. But in order to recover damages, the injured party, or plaintiff, must prove that:
- The defendant acted in a negligent manner.
- Their negligence caused the plaintiff to be injured.
- The injury caused the plaintiff to suffer damages.
The plaintiff must also show proof of the amount of damages that resulted from the injury. These damages might include medical expenses, lost wages, property damage, the loss of future earning capacity and pain and suffering.
Although workers’ compensation provides financial and other benefits to an injured worker, the amount is relatively modest compared to the awards that can be obtained in a personal injury lawsuit. Personal injury cases sometimes produce awards in the thousands or even millions of dollars, but there is no guarantee what kind of award a case might bring, especially if it goes in front of a jury.
Personal injury cases may be initiated immediately after an injury, or any time up until the statute of limitations has expired. In Florida, this time period is within four years from the date of the accident. If the matter cannot be settled out of court, the plaintiff’s attorney will file the lawsuit in civil court.
Workers’ Compensation Claim or Personal Injury Lawsuit?
It is not necessary to establish proof of fault in workers’ compensation cases. However, once benefits are awarded, the injured worker gives up their legal right to sue the employer for personal injury or wrongful death, except in certain limited situations:
- The employer was required to carry workers’ compensation insurance, but failed to do so.
- The employer intentionally caused harm to the employee.
- The injury involved a defective product or a toxic substance.
- The worker was injured due to the negligent conduct of someone other than his or her employer or a co-worker.
Under those circumstances, an injured employee might be able to pursue a personal injury lawsuit against their employer or a negligent third party. Generally speaking, though, most workers are barred from suing an employer for a workplace injury, as long as they are covered by workers’ compensation insurance.