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As discussed last month, we have seen a recent trend of insurance companies denying injured employees’ claims for workers’ compensation benefits. As a result, if you have recently had your workers’ compensation claim denied, you are not alone. In this situation, it is essential to make sure you know your options—and to make sure you take action before you lose the options you have available.

So, what can (and should) you do?

While some workers’ compensation denials are justified, many are not. If your denial was unjustified, you can file an appeal. Keep reading to learn about the grounds for filing an appeal, the steps involved in filing an appeal, and why it is essential to hire an experienced workers’ compensation lawyer to represent you (which costs you nothing out-of-pocket).

What You Need to Know if Your Workers’ Compensation Claim Was Denied

The most important thing you need to know is that a denial is not necessarily the end of your workers’ compensation claim. If your denial was wrongful, you have clear legal rights, and an experienced workers’ compensation lawyer can assert your legal rights on your behalf. Here are seven more essential facts to know if your workers’ compensation claim was denied in Wisconsin:

1. Why Was Your Workers’ Compensation Claim Denied?

When facing a workers’ compensation denial, one of your first steps should be determining why your claim was denied. This will then allow you (or your lawyer) to determine if you have grounds to file an appeal.

As we said above, some workers’ compensation denials are justified. For example, if you are not an eligible employee or did not file your workers’ compensation claim in time, you may not be entitled to benefits (though you may have other options for seeking financial compensation). However, filing an appeal could be your next step if your denial was unjustified, which is not uncommon.

2. Is the Denial Unjustified?

When is a workers’ compensation denial unjustified? As we discussed in our previous article, some of the most common reasons for workers’ compensation denials include the following:

  • Not reporting the work injury promptly
  • Inadequate medical documentation of the injury
  • Inadequate other evidence of the injury or its cause
  • A dispute about whether the injury is work-related
  • A dispute about a pre-existing condition
  • Violations of company policy
  • Failure to cooperate during the claims process
  • Missing deadlines during the claims process
  • Employee classification issues
  • Inconsistent or conflicting statements

While these can all potentially be legitimate grounds for denying a workers’ compensation claim, insurance companies frequently use these as excuses to unfairly deny benefits to injured workers unfairly. Your workers’ compensation lawyer will be able to determine if your denial was unjustified, and if it was, your lawyer will assist you with fighting for the benefits you deserve.

3. Do You Have the Documentation You Need to Prove Your Right to Benefits?

In some cases, overcoming a workers’ compensation denial involves providing additional documentation to the insurance company. While workers’ compensation insurance companies are obligated to process injured employees’ claims in good faith, they do not have to pay benefits if there is a legitimate question about whether benefits are owed.

Once you determine the reason for your denial, one of the following steps is determining if you have (or can obtain) the documentation you need to prove your right to benefits. Your workers’ compensation lawyer can assist with this as well, and, depending on the circumstances, it may be possible to submit this additional documentation and secure the benefits you deserve without going through the formal appeals process.

4. Filing a Workers’ Compensation Appeal

If your employer’s insurance company is unwilling to pay the benefits you deserve, you will likely need to file a workers’ compensation appeal. Due to the stakes and complexity of the issues involved, having an experienced workers’ compensation lawyer on your side is essential.

You will need to file your appeal with the Wisconsin Workers’ Compensation Division. The Division’s Alternative Dispute Resolution (ADR) Unit will handle your appeal. Depending on the circumstances, at this stage, you may need to participate in informal alternative dispute resolution or attend a hearing at the ADR Unit, or both.

5. The Informal Alternative Dispute Process

The informal alternative dispute process allows you to obtain the benefits you deserve without going to a formal hearing. The ADR Unit can require insurance companies to participate in the formal hearing process; however, it cannot require them to agree to pay benefits.

6. Formal Hearings Before the Workers’ Compensation Division ADR Unit

If the informal alternative dispute process is unlikely to be effective or fails to produce a favorable outcome, you have the right to fight for the benefits you deserve at a formal hearing before the Workers’ Compensation Division ADR Unit. An administrative law judge (ALJ) at the ADR Unit will hear arguments and evidence from both sides, and then it will render a binding decision.

7. Appeals to the Labor and Industry Review Commission (LIRC) and Circuit Court

While the ALJ’s decision is binding, it is not necessarily the final word on your workers’ compensation claim. If you disagree with the decision, you can file another appeal with the Labor and Industry Review Commission (LIRC). If the LIRC rules against you, you can take your claim to Circuit Court. All of these are formal legal procedures that also require experienced legal representation.

Discuss Your Claim with an Experienced Madison Workers’ Compensation Lawyer for Free

Are you dealing with a workers’ compensation denial in Wisconsin? If so, we encourage you to contact us for a free, no-obligation claim assessment. To speak with an experienced Madison workers’ compensation lawyer at Mays Law Office in confidence as soon as possible, call us at 608-305-4518 or tell us how we can reach you online now.

The post What Can I Do if My Workers’ Compensation Claim Was Denied in Wisconsin? appeared first on Mays Law Office.

Mays Law

Lisa Pierobon Mays

Attorney Lisa Pierobon Mays, as the owner of Mays Law Office focuses her legal practice on representing Wisconsin workers who have been injured on the job. With more than twenty-five years of experience, she is dedicated to advocating for injured…

Lisa Pierobon Mays

Attorney Lisa Pierobon Mays, as the owner of Mays Law Office focuses her legal practice on representing Wisconsin workers who have been injured on the job. With more than twenty-five years of experience, she is dedicated to advocating for injured workers who have been unfairly denied their rightful workers’ compensation benefits by companies and their insurers. Lisa understands the profound impact of a work injury, including lost income, medical expenses, emotional distress, physical pain, and social isolation. She takes the time to listen to each client and develops a tailored legal strategy for their specific situation. Lisa is personally involved in every case from beginning to end, ensuring clear communication and recognizing the unique concerns, needs, and expectations of each individual she represents.

Stephen Mays

Attorney Mays, as the owner of Mays Law Office, LLC, practices in all areas of criminal and traffic defense throughout the entire State of Wisconsin. Prior to his becoming a defense attorney, Attorney Mays worked in the Dane County District Attorney’s office.

He has won OWI cases at the municipal, circuit, appellate and Supreme Court levels, and appears regularly before the Federal District Court of Wisconsin and the United States Court of Appeals for the 7th Circuit. He is also admitted to practice before the United States Supreme Court.

He is a past President and member of the Dane County Criminal Defense Lawyers’ Association, as well as a sustaining member of the National Association of Criminal Defense Lawyers, Wisconsin Association of Criminal Defense Lawyers, and the Bar Associations for the Western and Eastern Districts of Wisconsin. He has been a member of the James E. Doyle Inns of Court, as well as the National College for DUI Defense. He is one of the original members of the Drunk Driving Roundtable – an association of attorneys dedicated to the tenacious defense of citizens accused of drunk driving.

He was selected to be a member of the Department of Transportation’s Technical Committee, and has testified before various committees regarding proposed motor vehicle legislation, most recently convincing a sub-committee to not extend the territorial boundaries for OWI enforcement. He is a frequent lecturer on the defense of intoxicated driving, which includes an annual presentation by the Wisconsin Association of Criminal Defense Lawyers in the “Strategies in Handling OWI Cases in Wisconsin” series, a seminar touted as a “must attend” for Wisconsin lawyers defending OWI cases.

Several of Attorney Mays’ cases have attracted substantial media attention, including the successful defense of an individual charged with killing his twin infant daughters while allegedly driving drunk. His cross-examination techniques have gained him statewide recognition as one which has police officers persuading prosecutors to amend charges so as to not have to subject them to his cross-examination again.

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