Resolve Your Workers Compensation Claim Dispute in 2023 [Strategies]
Dealing with a denied workers compensation claim or disputes over benefits can be incredibly frustrating. But there are strategies you can use to try to resolve issues and get your claim back on track in 2023. With persistence and the right game plan, you may be able to reach a fair settlement or decision without having to go to court.
Understand Why Your Claim is Disputed
The first step is understanding why your workers comp claim is being disputed. Some common reasons include:
Disagreement that the injury occurred at work
Dispute over the medical treatment prescribed
Debate over the extent of disability
Argument regarding your ability to return to work
Preexisting conditions complicating the claim
Issues around compensation amounts and duration
Knowing the exact dispute points allows you to better target your resolution efforts.
Gather Documentation
Strengthening your claim with documentation showing your injury and eligibility for benefits is key. Key documents to collect:
Medical records - Records from date of injury, ER visits, doctor appointments, surgery notes, therapy notes, medication lists.
Accident reports - Any reports filed with employer when injury happened.
Expert opinions - Reports/letters from doctors addressing your injury, treatment, work capacity.
Work logs - Records of hours worked, duties performed, accommodations required.
Communication logs - Notes documenting contacts with insurer and employer.
Wage/employment info - Pay stubs, W-2s, personnel files showing your earnings and history.
Evidence of disability - Records demonstrating how injury impairs your capacity.
Thorough records help back up your claim if you need to take it to court.
Try Calling the Adjuster
One simple attempt to resolve a dispute is to directly call the claims adjuster and discuss the issue politely. Explain your situation, highlight facts the adjuster may be missing, and ask respectful questions. Maintaining open communication can sometimes resolve misunderstandings.
Send a Dispute or Appeal Letter
Putting your dispute request in writing is wise. Draft a letter to the insurer or workers comp board laying out your position. Explain what is being disputed, provide supporting facts/documents, and request a reconsideration. Be clear and logical in presenting your side. Ask for a written response by a specific date. Keep the tone professional. Sending letters by certified mail provides proof of your efforts.
Request a Hearing
If unsuccessful resolving a dispute directly, the next action is requesting a hearing before the state Workers Compensation Board. There are usually straightforward forms to request a hearing - your attorney can assist. At the hearing, both sides present evidence before a judge who then makes a binding decision. Having an experienced workers comp attorney represent you is extremely beneficial for hearings.
Get an Independent Medical Exam
A key dispute point is often the nature and extent of the injury. Seeking an independent medical exam (IME) from an objective doctor provides a respected third-party opinion. Choose a doctor known for fairness and your attorney can ensure they receive your records ahead of time. Being as transparent as possible with the examiner helps achieve an accurate assessment. This can carry more weight than opinions from doctors hired by the insurer.
Consult with a Workers Comp Attorney
Hiring an attorney experienced specifically in workers compensation law can be invaluable if your claim is mired in disputes. They know how to navigate the system and resolve issues. An attorney can:
Examine the facts and provide an assessment of your claim's merits
Handle communications/negotiations with insurer and employer
Assist with evidence gathering and documentation
Represent you at hearings before the Board
Ensure deadlines are met and your rights protected
Find an attorney well before any statute of limitations expires. Most offer free consultations to review your case.
Negotiate a Compromise Settlement
If you want to avoid drawn-out litigation, a compromise settlement negotiated between you, your lawyer, and the insurer is an option. The insurer agrees to pay you a lump sum amount to close the claim in exchange for releasing them from future liability. Settlements often make sense once you've reached maximum medical improvement. Having experienced legal counsel is key for obtaining a satisfactory settlement amount.
Alternative Dispute Resolution
Some states provide alternative dispute resolution options like mediation or arbitration to resolve workers comp issues outside of court. A neutral third party facilitates negotiation between you and the insurer to aim for a compromise. Or presents a decision after hearing both sides. Discuss with your attorney whether ADR makes sense for your situation. It can potentially save time and expense.
File an Appeal
If your claim is outright denied, you have the right to file an appeal. This involves requesting the Workers Compensation Board or appeals panel review the claims decision. You must abide by the appeals process and deadlines in your state. Your attorney can handle filing the proper forms and paperwork. New evidence or documentation and clear arguments may overturn a denial.
Take Your Claim to Court
If you exhaust all other dispute resolution avenues without satisfactory results, your last resort is taking your claim to court. Your attorney files a petition and lawsuit against the insurer or employer contesting their claim decision. Both parties go through evidence discovery before the court date. You'll want a highly experienced attorney to litigate in court and look for indicators your claim could win before pursing this costly route.
Tips for Resolving Your Claim Dispute
- Immediately request hearings or appeals deadlines if benefits are denied
- Thoroughly document communications, injury details, work history
- Be cooperative with medical exams requested by insurer
- Honestly assess how strong your claim is before prolonging fight
- Comply with all prescribed medical treatment
- Maintain a respectful, constructive tone with insurer and employer
- Consider mediation before resorting to court litigation
- Consult an attorney sooner than later if disputes arise
Conclusion
Disputes undoubtedly add frustration on top of dealing with a work injury. But utilizing the right strategies - gathering evidence, negotiating respectfully, obtaining legal representation - can help resolve claim issues and arrive at a satisfactory outcome. Knowing your rights and evaluating your claim strengths allows you to determine the most prudent path. With persistence and preparation, you can achieve a fair workers comp result and move forward.