Jerome, Salmi & Kopis, LLC – Law Firm in Fairview Heights, IL

Why is My Workers’ Compensation Case Denied?

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People throughout Illinois and Missouri are hurt at work every day. After a workplace accident that results in serious injury, you may be left with high medical bills, lost income, and more. Most employees are entitled to receive workers’ compensation to recover some of these losses and to ensure they have the resources necessary to get better.

Unfortunately, employers and insurance companies do not always provide employees with the compensation they need. When this is the case, you will likely wonder why your claim was denied, and what you can do to receive the compensation you need. Below, our workers’ compensation lawyers at JSK explain. Contact us today so we can help you.

Common Reasons for Workers’ Compensation Denials

Sometimes, employers and insurance companies may provide legitimate reasons for denying your workers’ compensation claims. Other times, they may create reasons for a denial, so they can retain more of their profits. The most common reasons for denying workers’ compensation claims are as follows:

  • Incomplete report: You must inform your employer of the accident and resulting injuries as soon as possible. Provide this notice in writing and include how you were hurt on the job, clarify that you did not suffer from a pre-existing injury, and ask for a list of approved doctors, if applicable.
  • Injury not reported on time: Again, you must notify your employer about the workplace accident that resulted in injury. You should do this as soon as possible so that you can start receiving benefits in a timely manner and so your employer does not use a delay in notice to deny your claim. In Illinois, you have only 45 days to notify your employer and in Missouri, you only have 30 days to provide notice.
  • Pre-existing conditions: Employers often try to avoid paying workers’ compensation by arguing that an injury is a pre-existing injury. For example, a worker may have to lift heavy boxes regularly and hurt their back. Their employer may argue the injury is not due to lifting boxes, but another reason entirely. It is important to note that even if you have a pre-existing injury, you can still likely claim workers’ compensation if a workplace accident aggravated it.
  • You were not working at the time of the accident: In both Missouri and Illinois, workers’ compensation law stipulates that individuals must have been performing employment duties at the time of the accident in order to claim workers’ compensation. However, this does not mean you have to be at the site of your employment. Even if you were not on-site, but you were still performing work duties, you are likely still eligible to collect workers’ compensation.
  • Your employer argues that you were at fault: In both Illinois and Missouri, workers’ compensation is a no-fault system. This means you might still receive benefits even if you caused or contributed to the accident that caused your injury. However, if you were under the influence of alcohol or drugs and became injured, it may be a valid reason for your employer to deny your claim.

Regardless of the reason for a workers’ compensation denial, it is incredibly frustrating to learn that you may not receive the benefits you need. Fortunately, there are ways you can still try and obtain the necessary compensation.

Steps to Take After Being Denied Workers’ Compensation in Illinois

If you have been denied workers’ compensation, it is easy to think that you are out of options. Fortunately, there are steps you can take to receive the benefits you need. In Illinois, these are as follows:

  • Apply for benefits: The first thing to do after being denied workers’ compensation in Illinois is to file an Application for Adjustment of Claim with the Illinois Workers’ Compensation Commission (IWCC). In most cases, you must file an application for an adjustment of claim within three years after suffering an injury.
  • Request a hearing: Once you have filed your application for an adjustment of claim, you will be assigned a case number and an arbitrator. You will then have an opportunity to request a hearing with the arbitrator to discuss your case. If there are issues in your case that are time-sensitive, you can even request an emergency hearing.
  • File an appeal: If the arbitrator does not decide in your favor and further denies you workers’ compensation benefits, you can also appeal their decision. To do this, you have to file a form known as the Petition for Review of the IWCC arbitrator’s decision. You must file this claim within 30 days. You will then need to argue your case during a hearing before the IWCC. Once the hearing is over, the Commission must make a decision within 60 days. It’s best to let a lawyer at JSK handle this for you.

Steps to Take After Being Denied Workers’ Compensation in Missouri

The first step in appealing your case is to contact the Dispute Management Unit so you can request mediation. During mediation, you will meet with your employer or their insurance carrier to discuss the dispute and try to reach a resolution. Mediation must be entered into voluntarily, meaning the other side will have to agree to participate. If the other side is open to mediation, a mediator will contact you to discuss the case and will also facilitate negotiations with the other side in an attempt to help you reach an agreement. If you cannot resolve your case during mediation, you can file a Claim for Compensation with the Division.

If mediation fails, you can request a conference with an administrative law judge. To do this, you must complete and submit a Request for Conference form, which you can obtain from the Division. After submitting this form, you will receive a notice informing you of the details about when and where the conference will take place. The conference is a meeting between you and your employer or the insurance company. If the issue still remains unresolved, you can file a Claim for Compensation.

A Claim for Compensation is the first formal level of appeal, and it is also required if you wish to continue the appeals process. The steps when filing a Claim for Compensation include:

  • The pre-hearing: After you file the Claim for Compensation, you can then file the Request for Pre-Hearing to set a date for your pre-hearing conference. At the pre-hearing conference, you will meet informally with your employer or their insurance carrier. You must attend this pre-hearing to try and resolve your dispute with the other side again, or if you did not attend mediation prior to this point in your case.
  • Mediation request: You can also file a request for formal mediation. This step is appropriate if there are issues that need resolving before your appeal can continue. For example, if a final rating report has been issued but you do not agree with it, or you have been denied your request for medical treatment while your doctor is recommending further treatment, you may have to enter mediation.
  • Request for hearing: During your appeal, you can request either a hardship hearing or a final hearing. If your physician has determined that you have not reached maximum medical improvement (MMI) and you need further treatment or temporary total disability benefits, you can request a hardship hearing. If you have reached MMI, you can request a final hearing. MMI refers to the fact that your injuries have healed as much as they are going to and that while you will not get any better, you also will not get any worse.

No matter what type of hearing you are requesting during your workers’ compensation appeal, you should prepare for a formal legal hearing, which means you should be represented by a workers’ compensation lawyer at JSK. Our attorney will present important evidence in your case so they can prove the pertinent facts of your case.

Once the judge has heard from both sides during the hearing, they may then award you with three types of awards. The first is a final award. It is a final decision made by the judge on the appeal in your case. If you are unsatisfied with the decision, you can file an appeal with the Missouri Labor and Industrial Relations Commission.

Temporary or partial awards are usually given after a hardship hearing, and they only address the issues relating to benefits or medical treatment. Your case is still considered open at this point, and until a decision on a final award is made. You can also appeal this decision with the Commission.

Lastly, an “award on agreed statement of fact” will only address legal issues if both parties completely agree on the facts of the case.

Call Our Workers’ Compensation Lawyers in Illinois and Missouri Today

If your claim has been denied, our Missouri and Illinois workers’ compensation lawyers can assist with your case. At the Law Office of Jerome, Salmi & Kopis, LLC, our seasoned attorneys will prepare you for every step of the process and help you claim the full benefits you justly deserve. Call us now at (618) 726-2222 or contact us online to schedule a free consultation.

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