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.
What To Do If Your Compensation Claim is Denied
File Your Claim for Benefits Form
If the insurance carrier has denied your claim, you need to file the Claim for Benefits 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 for Benefits 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 for Benefits 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.
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.