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Payment or Denial of Workers’ Compensation Insurance Claim

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Workers’ compensation insurance coverage, also known as workers’ comp can give benefits to employees who suffer from a work related injury or illness. Workers’ compensation can protect your business and employees and also provide benefits to employees who are injured. Workers’ comp can help cover missed wages, medical expenses, vocational rehabilitation, or in extreme cases death benefits.

In Massachusetts, the claims reporting process requires an injured employee becoming eligible for weekly compensation benefits when they are physically unable to attend work for 5 or more calendar days as a result of injury or illness at work. The five days do not need to be consecutive. After missing work days, the employer is required to electronically fill out the Employer’s First Report of Injury / Fatality. If the injury or illness results in missing less than 5 full calendar days, then it is considered a “medical only” claim and does not have to be reported to the DIA.

Payment or Denial of Claim

Once the insurer receives the form, they have 14 days to pay benefits on an Insurer’s Notification of Payment Form. The insurer can also notify the employee and the Department of Intelligence (DIA) that they are denying the claim through an Insurer’s Notification of Denial Form.

For the first initial 180 days following the illness or injury the insurance company can pay on a claim without accepting a form. During this period, an insurer can modify or stop the payments after a 7 day calendar notice to the injured workers and the DIA.

The insurer can extend the initial 180 period for another 180 days on an Agreement Form. After the 180 day period, the insurer can stop and reduce payment for reasons specified from the Workers’ Compensation Act.

How is it paid?

Workers’ compensation benefits are ultimately paid for by the employers of the state. Worker’s comp systems vary from state to state, but the employers pay for workers’ compensation typically in either of these ways: premiums to state- run insurance program, directly to the workers, or to payments to an insurance company.

When receiving workers’ comp benefits, the company that you receive the workers’ comp benefits may or may not be your employer. The state government, the insurance company, your employer, or a third party hired from your employer may be held responsible for administering the employers’ workers’ compensation claims.

If you already have a workers’ compensation claim, the benefits you will receive are the same regardless or the route that the money takes from the employer to you. It is important to understand the organizations involved in administering the claim.

Insurance Companies

Most states allow employers to purchase workers’ comp insurance from private insurance companies. Liberty Mutual, Chartis, and others provide workers’ comp insurance to companies of all sizes. If your employer has a workers’ comp policy through a private insurance company, it is the company who will send workers’ compensation benefits.

State Run Programs

The employers may choose to obtain workers’ comp insurance through state run programs or insurance funds. The type of companies that chose the state systems to cover workplace injuries are small employers and employers in an industry with few workplace injuries.

If the employer is part of a state-run insurance program, the workers comp benefits will be paid out by the state department responsible for administering the program. The state department acts like insurance companies. When there is a claim once the employers pay premiums, the insurance company checks to see what benefits are owed, and then pays the injured party. As the injured or ill worker, you are the injured party receiving workers’ compensation benefits.

Self-Insurance

To self- insure, the employer must be large enough to prove that is has the assets to cover the expected workers’ compensation benefits and liability. Most states require self-insured companies to submit considerable oversight by the state to show that the proper steps are being follower and the workers are getting the full amount of workers’ comp benefits they are properly owed.

Many self-insured companies can use third party administrators for the self-insured employer. The third party administrator deals with paperwork, claims processing, and management of claims. The employer sends money to a third party administrator and then sends these funds to injured workers.

If your employer has self-insurance, considering hiring an attorney in the case that you are entitled to receive workers comp benefits that you have not yet received. Self- insurance employers have the most resources to fight the compensability of the claims (to pay benefits) and the eligibility for benefits, because of the greatest financial risk that workers’ receive from comp claims.

Why Workers’ Comp Claims are denied

If the Workers’ Comp claim was denied, the first thing that you should do is to find out why. This should be said through a denial letter. It is possible to be denied for not meeting the simple eligibility requirements. If you believe the denial was an error, you may appeal. Common reasons for a denial of workers’ comp benefits include:

  • Injury was not reported in time: The state typically requires the supervisor to report the incident within a few days.
  • Claim was not filed on time: State laws require that deadlines to file an initial claim are typically within a range of 30 to 90 days.
  • Employer disputes claim: The employer may state that the accident did not happen or was the result of horseplay.
  • Injury not compensable: Claims for stress related injuries are hard to prove in some states and easier in others.
  • No medical treatment: For most cases, you must obtain medical treatment to receive workers’ comp benefits.
  • Insufficient evidence that injury is work related: Not always clear to prove whether or not an injury happened while at work. Having additional evidence and witnesses can prove your case.

How to appeal a Denial Claim

The letter of denial will provide a deadline date to appeal the claim that is made. Meet with your employer to go over how the dispute should be resolved in order to launch the claim. It can be a clerical error or a simple misunderstanding. To appeal the decision, bear that it can be a complicated process that is handled by the workers’ comp attorney.

The appeal process varies by state, but also involves a hearing with an administrative judge. There are multiple levels of appeal but check the state laws for more details.

Bring any documentation including medical records that address the reason for denial. This could result in a second medical exam, a time sheet showing that you were working during the injury, and other evidence. It could result in a second examination with the time of injury.

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