Workers’ compensation is unfortunately not a guarantee for all work injury cases. For a number
of reasons — such as the failure to prove the injury’s relation
to work or neglecting to follow certain processes — your claim could
be denied. If your employer denies your claim completely, you have the
right to file an appeal. But what can you do if your workers’ compensation
claim is only partially denied?
It’s possible that your employer’s insurance company will accept
your claim, but deny you coverage for a specific type of treatment. Partial
claim denials can be appealed, but the process could differ from the process of appealing
a complete claim denial.
Types of Partial Workers’ Compensation Claim Denials
Like any insurance provider, there are limits to what is and isn’t
covered by your employee’s insurance company. Although your original
offer for workers’ compensation benefits may provide some coverage,
you may not receive coverage for certain things.
Your employer’s insurance company may provide you with some workers’
compensation benefits, but deny coverage for:
- A single injury (possibly if it is related to a preexisting condition)
- Treatment (such as a certain type of surgery, medication, or rehabilitation)
- A medical provider
Why Was this Portion of Your Claim Denied?
To begin your process of appealing a partial workers’ compensation
claim denial, you will need to understand why that piece of your coverage
was denied in the first place. Often, claims are denied because your employer
does not believe your injury was work-related. The insurance company may
believe certain injuries were caused by your work, but deny the occupational
relation of other injuries. In cases of treatment denials, it’s
possible that the insurance company believes that treatment is not necessary.
When coverage for a medical care provider is denied, it may be because
that provider is not approved by the company or the workers’ compensation board.
Establishing Your Case for Coverage
Once you understand the reason for your claim denial, you can begin establishing
a case to combat the denial. You will need to provide evidence of your
injury’s work relation or proof of why you require the treatment
or medical provider that was rejected.
Partial workers’ compensation claim denials can be appealed to the
state workers’ compensation board, similar to the process of appealing
total claim denials. In many cases, the testimony of an expert witness
(such as your doctor) can establish the qualifications of your case. Our
attorneys can help you get the compensation you deserve.
Whether you are facing a partial claim denial, complete claim denial, or
are just beginning the workers’ compensation process, contact the
Law Offices of Wax & Wax to discuss your case.
Call 818.946.0608 or use our free consultation form
to get in contact with our lawyers.