Workers’ compensation laws in Oregon and most states around the country were developed to provide workers with access to medical care when injured on the job. The alternative of forcing them to sue their employers caused workers to delay medical treatment until they knew that a court would order their employers to pay for it. Workers’ compensation laws removed the uncertainty by eliminating lawsuits against employers in favor of a system that makes benefits available to medical care and lost wages available to workers unless a claim is denied.
Approximately 12% of the claims for workers’ compensation benefits filed each year in Oregon are denied. When this occurs, injured workers should consult with a Bend workers’ compensation attorney for the options available to them to challenge the denial and enforce their rights to benefits.
Common reasons for denial of a claim for benefits
State law requires that employers provide workers’ compensation benefits to their employees, either through an insurance policy purchased through a company offering workers’ compensation insurance or by becoming a self-insurer. A company must meet financial guidelines set by the state in order to qualify as a self-insurer for workers’ compensation claims.
When an accident or work-related illness causes a worker to need medical care, a claim for benefits is filed and must be approved by the insurance company or the employer. Workers’ compensation is a no-fault system, which means fault, even on the part of the injured worker in causing the accident, is not a factor. Reasons for a denial of a claim for benefits include the following:
- There was a delayed filing of an initial claim for benefits: Injured workers must notify their employers as soon after the accident or illness as possible, but in no event shall the notice be given more than 90 days after the cause of the injury. Immediately reporting the claim in writing using Form 801 makes it difficult for employers or insurance carriers to dispute the timeliness of the claim.
- The injury or illness was not work-related: An accident occurring at the place of employment with dozens of witnesses probably does not result in a denial of the claim for benefits as being outside of the scope of the worker’s employment. However, insurers or employers may contest the merits of a claim that cannot be substantiated by witnesses, videos, or other documentation. An injured worker should take note of witnesses to an accident and get their names and contact information to use in the event of a denial of claim.
- There was a lack of medical documentation of the injury: A physician treating a patient for a work-related injury must complete an official report for the workers’ compensation insurance company using Form 827. The information contained in the medical report must be consistent with diagnostic tests and the treatment records maintained by the doctor to avoid a denial of the claim.
- The claim arose outside of the scope of a person’s employment: Employers or their insurers will dispute a claim for benefits arising from an injury or accident occurring outside of the scope of a worker’s employment. For example, a truck driver injured in a traffic accident risks having a claim for worker’s compensation benefits denied if the accident occurred when the driver deviated from an assigned route to engage in personal business.
Filing a timely application for benefits with ample documentation to prove the nature and extent of the injuries and how they occurred may not be enough to avoid a denial of claim by an employer or the workers’ compensation insurance company handling it. If that happens, workers have the right to appeal the decision, but they must take immediate steps.
Appealing a denial of claim
A worker must be sent a written notice of the acceptance or denial of a claim for workers’ compensation benefits within 60 days from the date that the Form 801 notification was filed with the employer. If the claim is denied, a worker has the right to request a review of the denial by the Workers’ Compensation Division by filing a written Request for Reconsideration within 60 days from the date that the notice of denial was sent.
The process of appealing a denial of claim begins with a request for reconsideration. The Workers’ Compensation Division has up to 18 days to make a decision on the request, but it may delay doing so for an additional 60 days. The additional time may be needed to arrange for a medical arbiter examination. The examination may be conducted by a physician or a panel of physicians, none of whom have any prior connection to the case, with a report of the examination provided to the Workers’ Compensation Division.
Reconsideration by the Workers’ Compensation Division results in a decision without a formal hearing. Either the worker or insurer may appeal the reconsideration decision by requesting a formal hearing through a written request that must be filed within 30 days from the date of the reconsideration decision.
Retaining the services of a skilled Bend workers’ compensation attorney
The complexity of the process to appeal a denial of a claim for workers’ compensation and the fact that a worker’s wellbeing is at stake require legal representation by an experienced Bend compensation lawyer. Presentation of evidence at a formal hearing conducted by an administrative law judge designated by the Workers’ Compensation Division can be critical to the outcome of the appeal. In the event of an adverse decision, a workers’ compensation attorney may, depending upon the facts and circumstances of a particular case, recommend further appeals through the state court system.