Author: Randi Proukou

Claim Denied

WHY WAS MY WORKERS’ COMP CLAIM DENIED?

You suffered an injury on the job.  Maybe you strained your back while lifting something heavy.  Maybe you felt a pop in your knee when climbing down a ladder.  Perhaps you have developed wrist pain and weakness after years at the computer.  However the injury occurred, it happened at work and you feel you have a valid Workers’ Comp claim.

But one way or another, you find out your claim has been denied.  Why would this happen?  Let’s discuss some of the reasons why a Workers’ Compensation claim may be denied.

Notice to your employer

As soon as you are aware that you have an injury that happened on the job or as a result of your work activity, you need to immediately notify your employer – your supervisor or Human Resources representative.  They should have an  accident report or form to complete to take down information regarding your injury. You have thirty (30) days from the date of injury to provide proper notice to your employer.

Notice to the Workers’ Compensation Board

In addition to notifying your employer, a claim needs to be filed with the Workers’ Compensation Board.  This is not your employer’s responsibility.  A C-3, Employee Claim Form, (which can be found on the Workers’ Compensation Board website) needs to be filled out and submitted within two (2) years of your work related injury.

Medical Evidence

A Workers’ Compensation claim has strict requirements when it comes to medical evidence to prove your case.  Your medical provider must provide a report which specifically identifies 1) a history of your work activity, 2) a diagnosis of the injury, and 3) a statement that the injury is causally related to your work activity.  This is the basis of your claim and all Workers’ Compensation cases rely heavily on medical evidence.  Without these key pieces of information, a Workers’ Compensation Law Judge does not have a basis to establish a Workers’ Compensation claim.

Pre-Existing Condition

Having a pre-existing condition is a hurdle that can ultimately be overcome in a Workers’ Compensation claim; however, it is also a reason why an insurance company will initially deny a claim.   For example, perhaps you have had back pain and problems for many years for which you have seen your primary care doctor occasionally.  You experience a back injury while at work which causes you to lose time – maybe even require surgery.  An insurance company may try to allege that you had a preexisting back injury and use that as reason to deny your Workers’ Compensation claim.

Occupational Disease

We’ve talked about occupationally developed conditions in a prior blog “Work-Related Condition That is Not a Result of an Accident”.  Some work injuries develop over time and are not the result of a particularly identifiable incident.  These types of claims are often the most difficult for insurance companies to recognize and many times they are denied for that reason alone. 

So what do you do when your Workers’ Compensation claim is denied?  It is certainly no reason to give up!  A denied Workers’ Comp claim will likely require litigation and hearings at the Workers’ Compensation Board.  The insurance company will have an attorney representing them.  You should have an attorney to protect and fight for your rights. Contact Zea Proukou to further discuss the steps necessary to properly defend your claim. 

Can I get Workers’ Comp if I’m not at Fault?

You get hurt at work and it is not your fault.  And technically, it’s not the employer’s fault either.  Like with motor vehicle accidents, Workers’ Compensation in New York State is a no fault insurance based system.  So what does this mean for you?

The Workers’ Compensation system is designed to provide coverage for medical and wage replacement benefits for injured workers regardless of fault.  In order to establish a valid Workers’ Comp claim, you must have an accidental or occupationally developed injury that arises out of or in the course of your employment.  After properly notifying your employer, you must also produce medical evidence regarding your injury.  Specifically, your medical provider must put in writing a history of your work activity, a diagnosis, and a statement of causal relationship between your work and the resulting injury or condition.  This must then be filed with the Workers’ Compensation Board along with a C-3, Employee Claim Form. 

Now you are thinking, but my employer really is at fault!  Maybe there was a known issue on a machine and they still continued to run it.  Maybe there was a leak that resulted in an always slippery floor.  Even if the situation that resulted in your injury was clearly the fault of your employer, there is no payment or consideration for pain and suffering in the New York Workers’ Compensation system.  If there is some negligence that can be determined on the part of a third party, other than your employer, this would be handled by way of a separate, third party action claim.

Navigating these laws on your own can be difficult. An experienced workers’ compensation attorney can help you throughout the process and get you the benefits you deserve. If you believe your injury falls within these parameters, please contact us directly to further discuss that possibility. 

Workers’ Compensation Claim Tips

When filing a workers’ compensation claim there are a few things you need to keep in mind.  As with any set of laws, the NYS Workers’ Compensation system can be a difficult one to navigate alone.  If you are injured while working there are things you can do to help secure your claim and protect yourself.

Tell your Employer ASAP

If you get injured on the job, don’t wait, tell an authoritative figure with your employer. Each employer has different policies for reporting on-the-job injuries, so if you were injured on the job, be sure you report it immediately. Don’t wait for the pain to go away. Not reporting can result in a loss of benefits.

Be sure, when reporting the injury you completely and legibly fill out any accident report documents given to you by your employer. This form will likely be the first formal notification you are giving your employer. Be sure to mention exact details of your accident and any affected body sites, even if they are not where your pain is centralized.

As with any set of laws, the NYS Workers’ Compensation system can be intimidating and difficult to navigate alone.  Hiring a good attorney should be at the top of your list if you are hurt as it allows you to relax and focus on getting better, rather than trying to figure out state laws and paperwork on your own.

Fill Out the C-3, Employee Claim Form

It is also necessary to file an additional form with the Workers’ Compensation Board which will initiate a claim through the State.  There are timely claim filing requirements which if not followed, could result in the denial of your claim.  Do not wait for your employer to file documents for you.  You must be proactive on your own case.

See a Doctor

Up to date medical evidence which gives a history of your accident and symptoms, a diagnosis, and a statement of causal relationship are all necessary in successfully getting your Workers’ Comp claim established. Most family and primary care doctors do not accept work injuries anymore.  We can help you find a doctor that will see you for your injury.

Keep Records of All Expenses Related to Your Treatment

Keep track of your out-of-pocket expenses as these are generally reimbursable. Keep receipts for parking lot fees, bandages and over the counter medicines. You could even keep track of your mileage traveled to your physician or independent medical examiner.

Filing a workers’ compensation claim can be a daunting task. However, if you don’t wait to report the injury, hire an experienced attorney and see an authorized physician, you will be making this process much easier on yourself.