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Most employees injured on the job in Virginia are eligible to file claims for workers’ compensation benefits to cover their medical bills and wages they lose while off work for treatment and recovery. Workers’ comp is no-fault insurance that almost all VA employers with three or more employees must carry to cover work-related accidental injuries. You don’t have to prove your employer did anything wrong to cause your accident, and you can’t be fired or penalized for filing a claim.
If your injury is minor, your medical bills are low, your time off work is short, and neither your employer nor its insurance company disputes your claim, you might be able to handle the claims process on your own without the help of a lawyer. If, however, your claim is an expensive or complicated one with serious injury, high medical expenses, and significant time off work, there’s a possibility that it will be denied. Workers’ comp denials are more common today than ever before. If you receive a notice of denial, though, that’s not necessarily the end of your claim. You may appeal the denial at four different levels. Doing so with the help of an experienced workers’ comp lawyer definitely increases your chance of success in obtaining fair benefits.
Reasons for Workers’ Comp Claim Denials
Common reasons for denials of workers’ comp claims include:
Missed Deadlines
The Virginia Workers’ Compensation Commission (VWCC) gives you 30 days to report your accidental injury to your supervisor and two years to file a claim for benefits. If you miss either of these deadlines, your claim could be denied, leaving you with medical bills to pay and no money coming in to pay them.
Your best strategy is to report and file as soon as possible after your injury. Any delay on your part can be cited by the insurer as evidence that your injury is not as serious as you say it is or that it’s not work-related. A workers’ comp attorney can guide you through the claims process and make sure you meet all deadlines and other procedural requirements.
Insufficient Evidence
The insurance company’s adjuster might cite a lack of evidence in your report to prove your injury is work-related and prevents you from doing your job. The insurer could try to blame your current injury on a pre-existing medical condition. That’s why it’s best to include details of exactly when, where, and how your accident occurred in your report. Video footage of your accident, photos of your injury, and the names of any witnesses to the accident are also helpful to your claim. Your attorney can assist you by:
- Gathering, organizing, and presenting evidence of your work-related accident
- Introducing testimony or statements from your doctor(s) to prove the seriousness of your injury
Lack of Medical Treatment
Your claim could be denied if you do not seek medical attention soon enough. The symptoms of some injuries, like those suffered in a company vehicle crash, might not be immediately apparent, but you should still see a doctor as soon as possible after any work-related accident. A medical exam and diagnostic testing can reveal an injury that is currently asymptomatic. If you’re directed to a doctor certified by the insurer, see that doctor as soon as you can. If you’re not satisfied with that doctor’s diagnosis and treatment plan, your lawyer can help you seek an independent medical exam (IME) from a doctor of your choice.
Workers’ Compensation Appeals
If your workers’ comp claim is denied, you may appeal it at four different judicial levels.
Level 1: Evidentiary or on-the-Record Hearing Before a Deputy Commissioner
An evidentiary hearing is a formal proceeding in which evidence is presented by both parties (the claimant and the employer or insurer). Testimony is given under oath. An on-the-record hearing is a faster process for disputed claims that do not require a full evidentiary hearing. Decisions are based on submitted documents and written statements from both parties.
Level 2: Full Commission Review
Either party who disagrees with the deputy commissioner’s decision at Level 1 has 30 days to file a request for a full commission review. A transcript of the Level 1 hearing will be provided to both parties, who may file written statements arguing their respective positions on the claim. No other testimony or evidence will be considered. The VWCC may either make its decision on the basis of the submitted statements or schedule oral arguments if necessary. At the end of the review, the Commission will decide the case and issue its opinion.
Level 3: Virginia Court of Appeals
Either party who disagrees with the Level 2 decision has 30 days to file a Written Notice of Appeal with the VA Court of Appeals, post a $500 appeal bond with the Clerk of the Commission, and submit a Notice to the Clerk of the Court of Appeals along with a $50 filing fee.
Level 4: Virginia Supreme Court
Either party who is not satisfied with the decision of the Court of Appeals may appeal it to the VA Supreme Court, which may hear the case at its discretion.
An Attorney Can Help You Prepare for Your Hearing and Subsequent Appeals
At every level of appeal, your employer and its insurer will be represented by attorneys who have a thorough knowledge of workers’ comp law and the appeals process. While you’re not required to have a lawyer, you probably won’t stand a chance against your adversary without one. Your Level 1 hearing is very important because it provides your only opportunity to submit the evidence that will be used to make a decision on your appeal. Your attorney will be familiar with the hearing protocol and can be sure you take the following steps to increase your chance of prevailing:
- Make all medical reports and other relevant documents available to the Deputy Commissioner
- Provide the exact range of time during which you could not work due to your injury
- See that witnesses receive subpoenas directing them to appear
- Arrive on time for the hearing
Your Evidence
At your hearing, you will present your evidence and give your testimony first, explaining under oath how you were injured, when and to whom you reported your injury, your wages or salary at the time of your accident, and the names of your health care providers. If your doctor has released you with restrictions that limit you to a “light-duty” job, you must give evidence, including dates and locations, to prove you attempted to find and perform such a job. Both you and your witnesses will be cross-examined by the employer’s and insurer’s attorney.
Your Employer’s Evidence
After you’ve presented your case, your employer will submit its evidence and any witnesses supporting its denial of your claim. Your attorney may cross-examine such witnesses. In some cases, the VWCC might offer mediation services, at no additional charge, to help clarify the issues presented and bring the parties to some kind of agreement. After both sides have presented evidence, the deputy commissioner should issue a written decision within approximately three weeks.
