What To Do When Your Workers' Compensation Claim Is Denied
April 10, 2022
Workers’ compensation is a no-fault insurance system for injuries suffered at work and for workplace-borne illnesses, such as chemical exposure. Neither employee nor employer can be held liable for any accident, injury, or illness.
Employers often contract with private insurance companies to offer workers’ compensation coverage, and insurance companies are for-profit businesses. This means that they will challenge claims made by workers, limit compensation, or even deny the claim altogether.
If you have been denied a workers’ compensation claim in Billings, Montana, contact the workers’ compensation attorneys at Gerstner Adam Law. We have helped countless others obtain the compensation they deserve, and we stand ready to help you.
Our firm proudly serves clients in Billings, Glendive, Miles City, and Sidney, Montana.
The Workers’ Compensation
Employers are required, with certain exceptions, to provide workers’ compensation coverage for their employees. They can accomplish this through an insurance provider, self-fund the program themselves, or contract with the Montana State Fund.
If you are injured or fall ill because of a workplace condition, you need to fill out a First Report of Injury (FROI) form and get the employer or insurer to complete the form. When it’s completed, the form must be filed with the Department of Labor and Industry (DLI), which administers the state’s workers’ compensation system along with the Montana State Fund.
You can visit a doctor of your choice when first injured or ill, but after that, the workers’ compensation provider will designate a physician or medical group for you. The system should pay for all your medical expenses plus any wages lost due to time off from work.
Reasons for Denial of Your Claim
The workers’ compensation provider has 30 days to decide on your claim. They may deny your claim based on a variety of factors.
A major factor is that the injury stems from a pre-existing condition and was not caused by a work-related incident. This leads to another factor the insurer might cite: the injury or illness did not happen at work, it was the result of horseplay, or you were intoxicated or under the influence of drugs.
Other reasons can include you did not file your paperwork on time or failed to supply sufficient medical documentation.
Appealing the Denial
You have a right to dispute the denial with the insurance company, but if they still deny your claim or do not respond within 15 days, then you have to go through mandatory mediation by contacting the DLI and filing a form called Petition for Mediation Conference. A mediator will then conduct a conference call between you and the insurer to facilitate a settlement agreement.
If mediation fails to resolve matters to your satisfaction, the next step is to file a Petition for Hearing with the Montana Workers’ Compensation Court. You will then be notified of the date, time, and place for a hearing before a workers’ compensation judge. You have two years after your initial denial to request such a hearing.
Before your hearing, there will also be a pretrial conference. Both you and the insurer will be present and allowed to present witnesses, submit documents, and make legal arguments. Obviously, at this point, you need the help of an experienced workers’ compensation attorney. The assigned judge will then review everything and decide at your hearing.
If your appeal is still denied, your only remaining option is to appeal to the Montana Supreme Court.
Accepting a Settlement
At some point, the insurer may offer to settle with you, but remember that a settlement is final. If your injuries recur or get worse, you won’t be able to go back and ask for more compensation. Also, you should be aware that the offer will be for much less than you would have gotten if the full claim had been honored. It is the insurance company’s way of preventing further legal expenses and complications.
How an Experienced Attorney Can Help
We at Gerstner Adam Law are well aware of insurance companies’ tactics and ways of limiting or denying their claim liability. You should involve us from the start so you will be sure to provide sufficient medical documentation for your claim. If you’re denied, we can also stand with you and help you in all phases of the appeals process.
Contact us immediately if you have a workers’ compensation claim in Billings, Glendive, Miles City, or Sidney, Montana. The initial consultation is free.