If your workers’ comp claim is denied, you can appeal the decision by going through the Workers’ Compensation Appeals Board (WCAB). When appealing a workers’ compensation claim denial, there are certain steps that you will need to take, including filing a claim with the WCAB in your state.
What Is the Workers’ Compensation Appeals Board?
The WCAB is part of each state’s workers’ compensation agency. It may go by the name of the Workers’ Compensation Appeals Board in some states, but it might appear as the Workers’ Compensation Commission in others. In Illinois, for instance, it’s known as the Illinois Workers’ Compensation Commission (IWCC).
The role of the WCAB is to hear appeals for workers’ compensation claims after insurance companies or state boards deny them. Going through the WCAB in your state could give you another chance to file a successful workers’ compensation claim under the right circumstances with the help of a workers’ compensation attorney.
Understanding the Workers’ Compensation Appeals Process
If your insurer, employer, or state board refuses to pay a workers’ compensation settlement, you can initiate the appeals process with the WCAB or its equivalent in your state. The following is what the appeals process entails:
Review of the Appeal
The first step when you file a claim with the appeals board is for the board to review the appeal. You should submit any documentation you have that can support your claim and accelerate the review process. If you have plenty of supporting documents, this can significantly increase your chances of succeeding.
To file a successful claim, you should make sure you have evidence that proves a few key items. First, you should be able to prove that you were an employee at the time of the accident. In addition, you will need to show that the accident caused your injuries and that you reported the incident to your employer on time.
The Workers’ Comp Insurance Company or Employer Establishes Its Position
The next stage of the appeals process involves your employer or the employer’s insurer establishing its stance regarding the denial. At this point, employers and insurance companies can present any supporting evidence they have to prove that they had a valid reason to deny the claim.
For example, an insurer may claim that you sustained injuries from another unrelated accident. In other cases, employers may be able to prove that there wasn’t an employee-employer relationship between you on the date of the accident.
A Workers’ Compensation Hearing Takes Place
After the board reviews the appeal and employers or insurers have the chance to establish their positions, the representing attorneys for both sides can present arguments during a hearing. This will begin when the appeals board schedules a hearing before a commissioner or judge. Each side will then be able to discuss the case.
Application of the State’s Workers’ Comp Law
Following the hearing, it will be up to the commissioner or judge to decide whether to approve your appeal. Based on this decision, you may be able to receive benefits, or you may need to take additional steps to recover them. It can take over a month before the judge or commissioner reaches a decision.
Why Workers’ Comp Claims Are Denied by the Workers’ Compensation Appeals Board
There is no guarantee that the WCAB will approve your claim. Under certain circumstances, your employer, the employer’s workers’ comp insurance company, or the WCAB might choose to deny your claim.
Some potential reasons for denying a workers’ compensation claim include:
- The accident didn’t take place within the scope of your employment
- You willfully committed OSHA violations and workers’ compensation could not cover the injuries because of your intentions.
- You failed to notify your employer in a timely manner
- You neglected to seek medical treatment or didn’t see an approved medical professional
- Your injury developed because of a pre-existing condition
Whether initially filing a claim or going through the appeals process, you may want to hire a workers’ compensation lawyer to help establish the options available to you in your case.
How Many Times Can You Appeal a Workers’ Compensation Denial?
If the appeals board still decides to deny your claim after an appeal, you have the option of appealing multiple times. Each subsequent time you appeal, you will need to go through a different court to initiate the appeals process. As you progress through the different court systems, you may eventually file an appeal with your state’s Supreme Court.
There are five main levels of appeal, with differences between them to keep in mind:
In workers’ compensation cases, the first appeal level is conciliation. At this time, a designated conciliator such as a district hearing officer will be able to hear your appeal.
At this level, an administrative judge will preside over the case and review the details, including supporting documentation from both parties and their attorneys. This judge will then issue a decision within seven days of the hearing.
If the judicial conference results in a denial, you can still appeal with another hearing. This hearing will involve fully exploring all the evidence involved.
Department Appeals Board Review
A department appeals board (DAB) will hear the case if you don’t receive a favorable outcome with the evidentiary hearing. The board will look closely at all the previous decisions and details about the hearings to further determine whether it’s possible to reverse the denial.
State Supreme Court
The final level will be to file an appeal with the state’s Supreme Court, which will entail a federal court review.
By taking the right steps during the appeals process with the Workers’ Compensation Appeals Board, you may ultimately be able to see a reversal of your claim’s denial.