Workers’ compensation exists to provide benefits to employees who sustain job-related injuries or illnesses. When you get injured or become ill, you should be able to inform your employer and then, soon afterwards, have your medical care paid for and receive partial reimbursement for any wages you lost due to missing work. If your workplace injury caused permanent disability, you may be able to receive a lump sum settlement to cover future costs caused by your impairment. All of these workers’ compensation benefits can be critical to you and your household following a serious injury.
Because of the importance of these benefits, it can be shocking to receive a letter that your workers’ compensation claim has been partially or totally denied. You should know that there are options to appeal a denial, however, in order to do so, you should understand the reasons behind the denial in the first place. Our experienced attorneys can review your file and denial letter to determine why you were denied and what the best course of action may be to appeal. The following are some reasons why claims are commonly denied:
- Procedural mistakes — Under South Carolina law, there are specific procedures that you must follow in order to receive your workers’ compensation benefits, including informing your employer within a certain period of time and having a claim filed within a period of time. If any of the deadlines are missed, you may receive a denial. In addition, your employer or the insurance company may ask for certain information or documentation to support your claim. If you fail to provide that information or provide insufficient evidence, you may be denied.
You can find out the specific workers’ compensation claim procedures from your company or from an experienced attorney in South Carolina. If you need assistance to ensure that all procedures are followed or if you believe your employer is not following procedures, call us to discuss your case today.
- Disputes that your injury was work-related — In order for an injury or illness to be covered, it must have occurred either in the workplace or in the course of your job duties if it happened offsite. One common reason for denial is that your employer claims your condition was not actually work-related. There can be different reasons behind such a dispute. For example, if you drive as part of your job, your employer may claim that you were on a personal errand that was far outside of your job duties when an accident occurred. An employer can also claim that an illness was contracted in the normal course of life and not due to conditions at work. For example, if you have a breathing condition due to toxins in the workplace, your employer may claim that your condition is not specific to those toxins but may have been caused by environmental factors outside of work.
- Disputes regarding the severity of your injury — Just because you claim that your back injury is debilitating does not mean that your employer and their insurance company will automatically believe you. Instead, insurers often require evidence of your diagnosis and treatment plan and may even conduct independent investigation into your claim. This means that an investigator may be watching you in the days following your injury to determine whether you are as injured as you claim. If you state you cannot come to work and then the investigator witnesses you playing sports over the weekend, your claim may be denied.
Insurers can also question the severity of your injury to limit the amount paid for medical treatment or wage replacement. They may claim that certain treatments were not necessary or that your injury did not require as much time off work as you took. This can result in a reduction in benefits that can hurt your family.
- Not following the doctor’s orders — It is generally required that you seek proper medical assistance for your injury or illness in a timely manner in order to be compensated. If you fail to get diagnosed or visit a doctor after your injury, you may receive no benefits. However, even if you do visit a medical professional, your benefits may be reduced or canceled if your employer or the insurance company believes you are not following your doctor’s orders for treatment. If you do not undergo the recommended treatment, you may be accused of failing to mitigate or correct your injury and the insurer may refuse to continue to provide coverage. For this reason, it is always best to undergo all treatment recommended by your doctor, including rest periods and rehabilitation.
- Dispute of your disabled status — There are specific legal definitions of “disabled” under which you must qualify in order to receive disability benefits from workers’ compensation. If the insurance company argues that you do not qualify as disabled, your claim for long-term benefits may be denied. You may then have to present evidence from medical and occupational experts that the effects of your injury truly do render you disabled and unable to earn a living.
The above are only some of the many reasons why you may receive a denial and have to appeal in a workers’ compensation case.
Contact an Experienced South Carolina Workers’ Compensation Lawyer for Help
If you have been injured at work in South Carolina and your workers’ compensation claim has been denied or your benefits reduced, it is important to know that you have somewhere to turn for help. A denial is not the final say in whether or not you will receive benefits and the law provides many options to appeal wrongful denials. At the law firm of Ayers, Smithdeal & Bettis, P.C., our highly experienced team of South Carolina workers’ compensation attorneys have helped many people in and around Greenwood obtain the benefits they deserve for medical care and income replacement after a workplace injury. We offer free consultations and will provide personalized attention to make sure you get all of the treatment and payments that you need and deserve.