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Appealing a Workers’ Compensation Denial in Atlanta

Did you get hurt on the job in Atlanta and file a claim for workers’ compensation benefits? Has your employer’s insurance company denied your request? Don’t give up. You have the right to file an appeal, and Hanser Law can help you put your best foot forward.

We offer a free consultation, so give our Atlanta workers’ compensation lawyers a call to schedule yours today. Our skilled team will review your case, explain your rights, and answer any questions you might have about the appeals process and your claim.

You Have the Right to Appeal a Denied Claim for Workers’ Compensation Benefits

Workplace injuries are an unexpected hardship that can put your life out of balance. In fact, sometimes an injured employee must deal with more than just the physical trauma of an accident. There can be outstanding medical bills, rehabilitation costs, and even income lost during periods where going back to work is not possible.

Now, workers’ compensation laws were created to help lessen the financial impact of an on-the-job injury. The program is a form of insurance that most employers in Georgia are required to carry. Workers’ comp provides benefits that cover an injured worker’s healthcare costs and lost wages.

If you are injured on the job, you may apply for benefits by reporting the injury to your employer. Ideally, you would start receiving benefits soon after applying. But, unfortunately, the process doesn’t always go smoothly, and you may instead have your claim denied.

There may be a variety of reasons why you are denied workers’ comp. This is because the law is complex, and an insurance company is looking to protect its own interests. If this happens, you can have the action reviewed by the Georgia Board of Workers’ Compensation (“the Board”). If the Board denies your claim, you can then file an appeal in the court system.

Reasons Your Workers’ Compensation Claim Was Denied

An insurance company may deny a workers’ compensation claim for many reasons. But, note that an initial claim denial does not mean you are not entitled to benefits. There are many nuances and exceptions to the general rules, which may apply in your case.

That being said, the most common reasons for denial include:

  • Failure to report your injury to your employer within 30 days. However, there are key exceptions to this rule. One would be if your employer already knew about your injury.
  • Your injury did not occur while you were working. An example would be if you were on your lunch break or commuting to or from work. But, in some cases, a break may be covered. An example would be if you were still on the clock during your break.
  • You intentionally hurt yourself.
  • The injury resulted from horseplay, or your own misconduct. An example would be failing to follow safety instructions or working while being under the influence of a non-prescribed controlled substance.
  • Someone else intentionally injured you.
  • Your injury was the result of an accident that did not arise from your employment. An example would be an injury related to your pre-existing health condition, such as suffering a stroke or heart attack.

Note that you may also appeal claims that are not denied outright. Issues that can be the subject of these appeals include:

  • Determining your correct weekly wage
  • The suspension of your benefits based on a finding that you can return to work
  • A request to change physicians
  • Reimbursement for medical bills (such as an ER visit), and
  • A finding that you are partially disabled when you believe that you are totally disabled (meaning completely unable to work).

Hiring an attorney to help you navigate the appeals process can help to ensure that you’re in the best position to get the money you need and deserve.

Next Steps After Denial

If you are denied benefits, Georgia law gives you the right to appeal this decision. To begin the appeals process, you must file a notice of claim. This notice is on the state-provided form WC-14 and must be submitted within one year from the date the injury occurred. The form is filed with the Georgia State Board of Workers’ Compensation, with a copy sent to your employer and your employer’s workers’ compensation insurance company.

Note that even though you have a year to file, there are good reasons to act sooner. One reason is to preserve evidence for the appeal. Another reason is that the appeals process can take some time, so filing as soon as possible will help ensure that you get the benefits you need to pay bills more quickly should you win your case.

What to Expect at the Workers’ Comp Hearing

Once your claim is filed, the Board will schedule a hearing before an Administrative Law Judge (“ALJ”). The hearing is typically scheduled within 60 days of filing the claim form. It will take place in the county where your injury occurred.

An ALJ hearing operates much like a trial. You will have an opportunity to present evidence, such as medical records, as to why you should be entitled to benefits. The insurer will also present its ground for denial. You may have witnesses testify, and you will have the opportunity to cross-examine any witnesses that testify on behalf of the insurance company.

Once all of the evidence is heard, the ALJ will make a decision based on the facts presented and the applicable law. Note that you will not receive a decision on the day of the hearing. Instead, the ALJ’s findings will be mailed to you within the next 30 days.

Mediation as an Alternative to a Hearing

As an alternative to an ALJ hearing, you or the insurance company may instead request mediation. Mediation involves both you and the insurance company getting together before a mediator to informally negotiate a solution that works for both parties.

Requesting mediation is also done by filing Form WC-14, and checking the appropriate box. If the board approves your request, you must then attend the mediation at the scheduled time and place. Bear in mind that unlike a hearing before a judge, mediators do not make their decision through a binding order. Instead, it is up to both sides to come to their own agreement. It can be helpful to look at the mediator as playing the role of facilitator in this process of negotiation.

It is important to note that although mediation is less formal than an ALJ hearing, it is still important to fully prepare your case. Part of this process requires you to be able to establish what benefits you believe you are entitled to from the workers’ comp program and why. You should bring all relevant documentation you have to the mediation.

Now, all information presented during the mediation is confidential. This means that it cannot be used against you in any future hearing or court process. In cases where you and the insurance company are not able to reach an agreement through mediation, either party may opt instead to have a hearing before the Board’s ALJ.

Appellate Review of the Board Decision

If you believe that there was a mistake or error in a decision from the ALJ, you may file an additional appeal. This is done through the Board’s Appellate Division and the appeal must be filed within 20 days. An oral argument will be scheduled within 60 days of filing.

It is important to note that at this stage of the appeal process you are not allowed to introduce any new evidence. You and the insurance company will each file a brief and then will have 5 minutes to present your argument in person to the Appellate division. The Appellate Division is made up of three individuals who will determine whether a mistake was made during your hearing with the ALJ.

Now, because the ALJ was present for your hearing and heard all of the evidence presented, the Appellate Division will defer to his or her judgment. This means that the decision will only be reversed if there was something more than a difference of opinion over facts. There must clear error – an unquestionable mistake – that occurred in deciding your case.

Appealing to the Georgia Courts

The next option you have to appeal a workers’ comp denial is through the courts. You have 20 days from the decision of the Appellate Division to file your appeal with the Superior Court. The Superior Court will review the proceedings, briefs, and oral arguments. There will be no opportunity to present any additional evidence and there will not be any hearings.

Note that the Superior Court will only consider issues of law. This means that it will be assumed that the factual findings made in your case we correct. For example, if the ALJ determined that you failed to report your injury to your employer, this will be considered a fact, even if you feel your evidence proves otherwise. The Superior Court will then look to see whether the law was applied correctly to these facts and make a decision.

If you disagree with the Superior Court decision, you have 20 days to appeal your case to the Georgia Court of Appeals. The Court of Appeals will again limit its review to only the documents filed. There will be no new hearings or evidence presented and no findings of fact made. Note, that at each stage of the appeal process, it becomes less likely that a decision will be reversed.

Call Our Georgia Workers’ Compensation Appeals Attorneys Today

The law on workers’ comp and the appeals procedure can be complex. For this reason, you are entitled to have an attorney represent you throughout the workers’ comp claims and appeals processes. A qualified Atlanta workers’ compensation lawyer will be able to evaluate your case and determine whether you are eligible for benefits.

Keep in mind that it is important to have a workers’ compensation attorney involved early on in the process. Remember, the first hearing is your only opportunity to present evidence. If this step is not done properly, your chance of winning on appeal is very slim. Give our Atlanta law firm a call to get started on your workers’ compensation appeal today.

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