What To Do If Your Compensation Claim is Denied

If your claim for Virginia workers’ compensation benefits has been denied by the insurance carrier need to understand what steps to take in order to get medical treatment for your work injuries and to get the Virginia Workers’ Compensation Commission (VWC) involved in your case so you can have a hearing if necessary. This process can take some time as the system moves slowly, but you need to make sure you are doing everything within your power to keep things moving in the right direction until your case can be heard by the VWC.  I compiled a list of things you NEED to know if your case has been denied in order to set yourself up for the best possible outcome of your claim.

File Your Claim Form Form

If the insurance carrier has denied your claim, you need to file the Claim Form with the Virginia Workers’ Compensation Commission (VWC) and request a hearing. Once you have done this, if the insurance carrier still formally denies your benefits, then the Commission will set up a hearing date for both sides to present their cases before a Deputy Commissioner for a final determination.

Nothing will be paid until the claim is resolved-  If the Claim Form has been formally denied by the insurance carrier and you are waiting on the VWC to set up a hearing date, no benefits will be paid until the claim has been accepted by the insurance carrier, or until the claim is settled, or until there is a decision by the Commission awarding you benefits after a hearing. If you go to a hearing, you will need to wait for a decision which will be several weeks after the hearing date.  In that scenario, nothing will be paid until there is a decision by the VWC and, if you win, the other side does not appeal it.  If there is an appeal by the other side, it will be several more months until there is a decision on the appeal.

Get Medical Treatment On Your Own

If the Claim Form has been formally denied by the insurance company and you are waiting on the VWC to set up a hearing, you will have to get medical treatment on your own until the Commission hears your case and makes a ruling. This can take several weeks or even months and most injured workers have medical concerns that need to be addressed now.

If the claim has been formally denied, you are free to pursue your own medical care until the Commission determines otherwise. This can be a hardship for folks in a situation where they are injured, unable to work and may have lost their regular health insurance through their employer, and also not receiving a paycheck.

Our office has lists of free and reduced cost medical provides in Virginia, as well as contact information for public assistance for people who may need it to get through this difficult situation.  Getting medical treatment on your own is also imperative in pursuing your hearing as the VWC relies HEAVILY on medical records, work status slips (see #4) and statements from the doctor relating your current diagnosis, symptoms and need for treatment to the original work accident.

Get Work Status Notes From Your Doctor

Even if your claim is being denied, ALWAYS get a work status note from your doctor in writing – NO EXCEPTIONS! If you go to a hearing before the VWC you MUST have these in order to be awarded any lost wages, regardless of how severe your injury is you will not be paid any lost wage benefits without a doctor’s note.  You MUST have documentation of your work status for any period you are claiming lost wages.

Document Everything

If your claim is being denied and you are facing the possibility of going to a hearing before the VWC, make sure you keep good notes on EVERYTHING! Keeping a daily log of your symptoms and pain is a good idea for anyone getting treatment for a workers’ compensation injury and it is also a very wise idea to keep a log of any communications you have with your employer about your work abilities and any communications you have with your adjuster. Keep copies of any work status slips you have and you might even want to talk to your doctor’s office about getting a copy of your medical records. If you are on light duty, document all your job search efforts-you must be doing job searches if you’re not under an award order for lost wage benefits.  It is also wise to get copies of any accident reports, witness statements, police reports (if applicable) and medical records that are related to the accident.

Take a Settlement Instead of Going to Court

It really depends on the situation, but some injured workers may choose to settle their claim and forego the formal hearing with the VWC. This means that the injured worker and the insurance carrier have reached an agreed upon amount that they deem reasonable to close out the case and cancel the hearing. This can be a great option for some injured workers because if they opt for a settlement, they know up front how much they are going to receive and can often be a faster resolution that waiting on a hearing before the VWC. However, a settlement is not guaranteed to all injured workers and if a settlement cannot be reached the case can still go to a hearing before the VWC.

The Defense Attorney Is NOT Your Attorney

The defense attorney is hired by the insurance carrier to help them be successful in their denial of benefits and is looking out only for the best interest of the insurance carrier. I have injured workers call all the time and explain to me that they were talking with the defense attorney, who they thought was impartial (or even representing the injured worker!), and now they are confused that this attorney is now filing pleadings with the VWC on behalf of the insurance company. Or, I hear things like “the (defense) attorney told me the ________ was a good idea because ________.” You need to have an understanding of who you are talking to and what their role is in the workers’ compensation process before you decide to take advice from ANYONE!

Talk to a Virginia Workers’ Compensation Attorney

Make sure you are taking the appropriate steps in order to be successful in your case. Whether you choose to take a settlement or go to a hearing, get someone on your side who is there to look out for your best interests. Far too often I have seen folks attempt a hearing on their own, lose, then they try to hire an attorney.

No one will take their case because of the damage that has already been done and in most cases, it cannot be fixed. It is a horrible position to be in so please do not make this mistake – get it right on the first try (and pretty much the only try)!

If you have questions about your benefits or if you would like more information on the Virginia workers’ compensation system, order my book, “The Ultimate Guide to Workers’ Compensation in Virginia” by clicking this link, or call our office today (804) 755-7755.

When the Insurance Adjuster Says You Don’t Have a Claim

Insurance adjustors deny valid claims all of the time and most of the time they do this to save their insurance company money.  Many injured persons won’t pursue, and they save money. At the very least a denial creates a four to six month delay, which saves the insurance company a lot of money.

Many employers try to trick an injured worker by saying that if you didn’t notify us within 24 hours of the accident we’re not going to accept your case.  It may be true that they will litigate the matter but that does not mean that you are not entitled to file a claim and get benefits.  You actually have two years to file a claim.  You have to notify your employer within 30 days of your injury.  It really is not the employer’s decision or the insurance adjuster’s decision to make.  It is the Virginia Workers’ Compensation Commission that makes the decision whether you are entitled to workers’ compensation benefits.

Once, I actually had a client who was injured at work and his employer asked him not to file a workers’ compensation claim so the employer’s workers’ compensation insurance rates would not go up.  The employee agreed and signed a note in front of witnesses saying he was giving up all his workers’ compensation rights.  Obviously, when all his vacation and sick leave was gone and he was looking at two more major surgeries, he did not know what to do.  Luckily, he came to me and we prevailed at his hearing because he had given notice within 30 days and we filed within the two-year statute of limitations.  It was of no consequence that he had signed something to that effect.

The Process for Requesting a Hearing for Your Workers’ Compensation Claim

When you have been injured at work and you are denied benefits, you may need to request a Workers’ Comp hearing. It is usually in a worker’s best interest to secure legal help from a law firm in Richmond who understands workers law and rights.

The process for requesting a Workers’ Comp hearing generally involves the following: 

  • a claim for Workers’ Compensation in Virginia must be filed (whether or not you are being paid for missed time from work);
  • copies of medical records must be obtained from your doctor; and
  • medical records must be filed with the Virginia Workers’ Compensation Commission.

There are 2 parts to the form that must be submitted when requesting a hearing. It is usually best to attach your medical records to the form. If you are having difficulty understanding the forms, you may need to contact the Commission. In addition, if you are having trouble getting the medical records that you need, the Commission may also need to be contacted.

However, when you have questions concerning workers law and your right to benefits, you should seek legal counsel. The process of seeking Workers’ Compensation in Virginia is not necessarily an easy task.

Your employer or their insurance carrier may attempt to deny your claim. Even if you are eligible to receive benefits, you may find the process difficult to navigate. Many workers do not fully understand their rights as employees, which is why we can help. 

What Happens at a Hearing?

A hearing is a legal proceeding to determine what, if any, benefits are due under the Virginia Workers’ Compensation Act. A Deputy Commissioner will be present to hear all evidence and testimony.

The insurance company and employer will have an attorney representing their interests. The adjuster handling your claim may be present but not always. You will be asked to testify and to give your side of the story. Medical records, reports, and any other documentation in support of not only your claim but the insurance carrier’s claim, are submitted into evidence. Once each party presents their prospective case, the record is closed. The Deputy Commissioner will then issue an Opinion, weeks later, which is legally binding on both parties. There are various rules regarding whether a claim is able to be appealed and the time frame for doing so if either side wishes to seek an appeal.

If there is an appeal, no new evidence can be submitted during the appeal. If you are scheduled to have a hearing, you definitely want an attorney present to protect your rights.