Denied Worker’s Comp Claim?
I hurt my neck at work in February while lifting a patient. I’ve been receiving treatment with Worker’s Comp up until this point…but found out today that my claim was denied. They’re alleging that the car accident that I had in AUGUST was the “cause” of my neck injury…despite corroboration from my orthopedist AND physical therapist that the injury was acute…but I digress.
Here’s my question: I know I need to file a WC14 with the State Board of Worker’s Comp…but do I want to “request a hearing” or “request a mediator?” What’s the difference between the two?
I would suggest consulting an attorney, as laws differ slightly from state to state. In some states, requesting a hearing will automatically trigger an order that the parties mediate the matter prior to a hearing. That’s the way it is in NC, where any claim for hearing must be mediated by the parties before hearing.
Mediation is basically an opportunity for the parties to sit down across the table from one another with a mediator present (usually the parties agree informally on the selection of a mediator) to facilitate discussion of settling the dispute. Basically the insurer will come to the mediation with an amount of monetary settlement authority based on its analysis of its risk in the claim, and your job would be to see what their best offer to settle it at that time was and then decide if that amount was acceptable to you.
A hearing is where the parties actually litigate the claim on its merits.
I would definitely recommend retaining an attorney, as you’ll need one in either case. In the event you mediate your claim an attorney will be able to calculate the value of your claim-including the insurer’s exposure for future liability-and will be versed in negotiation tactics, and will be able to advise you if the amount offered is in your interest to accept in light of any weaknesses in your claim. If the matter is actually litigated the attorney will be versed in worker’s compensation law and the elements required to carry your burden of proof as the injured party.
Obviously it’s frustrating to have your claim denied, but you have to understand why the insurance company is doing it. They’re doing it as a cost-saving attempt. It’s not personal to them, it’s just a numbers game. But that doesn’t make it any more palatable for your situation, of course.
For every 10 claims denied, usually at least 3 claimants won’t even dispute the denial even if their claim is meritorious. And even if for those who fight the denial, the insurance company settles most of them through mediation for less than what they would pay if they accepted the claim and paid full benefits.
That’s not to say that if you mediate the claim you’re automatically going to get screwed on how much you’ll receive if you settle it. That’s why you need an attorney, because sometimes the amount offered in mediation will reasonably approximate what you might receive after litigation costs are deducted. And you need an attorney to help you decide if the cost of going forward to a hearing and the risk of losing your claim in light of its weaknesses is worth rejecting the mediation offer.
Finally, although from what you’ve said it sounds like you have a greater chance of winning than losing, you should always be aware that no disputed claim is ever 100% slam dunk airtight. Things can always go unfavorably, so always keep that in mind as your claim progresses and you have opportunities to resolve the matter without leaving it all up to the evidence and the hearing commissioner, who may be conservatively employer-inclined (it’s the luck of the draw, and usually these commissioners are attorneys who will one day look for employment in private firms…if they’re angling for a job with a WC defense firm they’ll lean the way of the employer if there’s any reasonable opportunity to do so).