What Should You Do When Your Workers’ Compensation Claim Is Denied?

Injured employees who make a formal claim for workers’ compensation must go through a process. To know how to respond to a claim denial, you should first understand that process.

Reporting a Work Injury

In many cases, injured employees can obtain workers’ compensation benefits without filing a formal claim. Whether or not it becomes necessary to file a claim, injured workers must give notice of the work injury to their employer within 30 days after it occurs.

Waiting 30 days might tempt the insurance company to argue that the injury was not related to work. It is best to notify the employer immediately after the work injury occurs. If a health condition (like a carpal tunnel injury) develops slowly over the course of time, notice should be given as soon as the employee suspects that the injury might be work-related.

Obtaining Medical Treatment

Tell your employer that you need medical treatment and ask how you should find a doctor. If you go to your own doctor, you’ll have to pay the doctor’s bill. Your employer is required to pay for your medical treatment, but your employer is permitted to choose your doctor. 

If your supervisor is not available, look for a poster that explains your worker’s compensation rights. It will provide information about medical treatment. It will also provide a telephone number for your employer’s insurance company. The insurer will need to authorize your treatment.

In an emergency, if your employer is not giving you the information you need, you can go to the nearest emergency room for treatment. If the injury is not serious or life-threatening, however, you risk having to pay for that visit yourself. If you aren’t getting any cooperation at all from your employer or its insurance company, talk to a Florida workers’ compensation lawyer.

Working with the Insurance Company

Shortly after reporting the injury, your employer’s insurance company should send you a brochure explaining your rights and obligations. You will probably also receive an accident report, titled “First Report of Injury or Illness.” You should read that document carefully to make sure it is correct. If there are mistakes in the report, you should alert the insurance company to those errors. It is best to do so by email so that you have written proof of the correction. You might also want to ask a workers’ compensation lawyer for assistance if you think the insurance company is misstating the facts.

The insurance company might also send you a release for medical records. You need to sign and return the release if you want to collect workers’ compensation benefits.

Finally, you will probably receive mileage reimbursement forms. You will use those forms to record your mileage for trips to the doctor for examinations and treatment. Florida law requires the employer to pay you a fixed amount per mile for those trips.

Florida Workers’ Comp Benefits

After you report the injury, you should start receiving benefits without the need to file a formal claim. Those benefits include:

• Medical treatment, provided by a doctor chosen by your employer or its insurance company.
• Temporary disability benefits if you miss more than 7 days of work. Those benefits replace a portion of your lost income because of your inability to return to full-time work. They are not usually paid for more than 104 weeks.
• Permanent disability benefits. Permanent benefits are payable if you still have an impairment after your injury has healed as much as it is ever likely to heal. Those benefits start when temporary disability benefits end. 

While the insurance company might look for ways to stop paying for treatment or to discontinue temporary benefits, most disputes that require injury victims to make a formal claim involve permanent disability benefits. Insurance companies rarely make the first offer of permanent disability benefits that equals the full value of the benefits an injury victim should receive. They often refuse to pay permanent benefits at all until the injury victim retains a lawyer or files a claim.

Filing a Claim

When an insurer denies a claim for benefits, in full or in part, the injury victim can file a Petition for Benefits with the Office of the Judges of Compensation Claims (OJCC). The petition must be filed within one year of the last benefit that the employer’s insurer paid. The injury victim’s lawyer will usually be in the best position to prepare a petition.

Claim Denial

After it receives the petition, the insurer has 14 days to pay the disputed benefit or to file a response denying the claim. If the claim is denied, OJCC refers the case for mediation. Mediation usually occurs with 130 days after the petition is filed. At mediation, the insurance company and the lawyer for the injured worker will try to negotiate a settlement.

If the case does not settle, it is referred to a workers’ compensation judge. The judge will schedule the case for a pretrial hearing. At that hearing, the judge will want to know which issues are being contested. After defining the issues and discussing the amount of time a trial will take, the judge will schedule the case for a workers’ compensation trial. That trial should usually be held within 90 days of the pretrial hearing.

Unlike the trial of a civil lawsuit, a jury will not decide the merits of the injured worker’s claim. The workers’ compensation judge is the decisionmaker. The judge presides over the trial, weighs the evidence, and decides whether the injured worker is entitled to the benefits that have been denied.

After the judge makes a written decision, the worker and the insurance company have 30 days to file an appeal with the Florida District Court of Appeal. An appeal is not a new trial. No new evidence is presented on appeal. Appeals are based on the argument that the judge misapplied the law or made an unreasonable decision. The appellate court’s decision is usually the last step in the case, although the appellate court will occasionally send the case back to the workers’ compensation judge to hold a new hearing or to apply a different legal rule to the evidence that the judge already heard.