Brabazon Law Office LLC Green Bay, WI  
 
 

Denied Insurance Payments: What To Do If There Is A Denial

     Unfortunately, although it may seem clear to the employees and their treating physicians that the injuries suffered took place at work, the insurance company does not always agree. Understandably, this often comes to a great surprise to the injured worker. There are several reasons an insurance company may deny payment of a workers compensation claim, some of which include the assertion it was a pre-existing injury, it did not take place at work, there is no injury at all, or the injury is not of the severity the employee asserts.

     The insurance company and employer are entitled to an examination of the injured worker by their own physician. This is called an Independent Medical Examination (IME). It is typically performed to assist the insurance company in a determination of compensability of the claim, the extent of disability, necessity of treatment and type of treatment, and to evaluate permanent disability or loss of earning capacity. A patient-client privilege does not exist between the worker and the examiner because the employee is not a patient of that doctor.

     The insurance company and employer are responsible for the expenses associated with an IME. They also must make payment to the employee for wage loss and travel expenses, including round trip mileage, meals and lodging. The wage loss must equal the total wages lost rather than the lesser disability benefit.

     Unfortunately, it is not uncommon for the insurance company to deny further payment of a claim after they receive the report from their Independent examiner. For this reason, the independent examination is a very important appointment for the injured worker to be properly prepared for. It is important for the injured worker to be honest with the examiner about their injury and the pain they are suffering. For more suggestions, contact the attorneys at Brabazon Law Office. They understand the process and procedures of an Independent Medical Examination, and take the time to prepare their clients for what to expect.

     Once the insurance company denies a claim, the employee must complete a Hearing Application and submit it in a timely manner to the Department of Workforce Development. A Hearing Application is the functional equivalent to a Summons and Complaint in a civil case. As this hearing application sets forth the injured worker’s entire claim, it is imperative that it is completed accurately and thoroughly.

     It is also necessary for the injured worker to attach medical support, set forth in a specific format, with the hearing application.

     When the employee is ready to proceed to a hearing, he or she should file a Certificate of Readiness. This tells the Department that he or she is prepared for a hearing any time. Typically, a hearing will be scheduled within six (6) months. The employee must make sure all medical support and reports are filed within the statutory guidelines. An Administrative Law Judge (ALJ) presides over the hearing. Each side presents testimony, reports and other evidence they deem pertinent to the case. Although worker’s compensation hearings are administrative and often more informal then those that occur in the Circuit Court, they generally are not very different from a trial. Therefore, familiarity with courtroom procedure is preferable. The ALJ issues a legally binding decision based upon his or her review of the findings at the hearing. This decision by the ALJ is issued as a formal “Order” to which the parties of the hearing must adhere.

     Often times, the insurance company will make attempts at resolution with the injured worker prior to the hearing. They may offer an amount of money to the client that is tempting. They often also require that it be a Full and Final Compromise, which means the employee is prohibited from filing any future claims against them for that date of injury.

     Despite the insurance adjusters’ seemingly kind ways, the injured worker must fully understand the value of their claim so that he or she is not selling themselves short. The attorneys at Brabazon Law Office are familiar with the tactics used by the insurance companies to limit or disprove a claim. Utilizing their legal experience and aggressive negotiating skills, the lawyers at Brabazon Law Office go the extra mile to ensure their clients receive all the worker’s compensation benefits they are entitled to. If you have any questions about an injury you have sustained while in the course of employment, contact Brabazon Law Office immediately to ensure you are receiving the benefits you are entitled to.

 


Brabazon Law Office, LLC P.O. Box 11213 Green Bay, WI 54307-1213 Phone: (920) 494-1106 Fax: (920) 494-0501 E-Mail: brabazonlaw@msn.com

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