If you were injured at work in Georgia, chances are you filed a claim for workers’ compensation benefits. State law requires most employers to provide employees with workers’ comp coverage from their first day on the job. Workers’ comp benefits should pay for medical expenses, a portion of lost wages, and certain other incidental costs when employees suffer occupational injuries or illnesses.
Unfortunately, workers’ compensation claims do not always proceed as they should. Every year, workers entitled to benefits see their claims minimized or outright denied by penny-pinching employers or insurance companies. If this has happened to you, you have the right to appeal your claim’s denial.
If your workers’ compensation claim was wrongfully denied, you have the right to appeal this decision. However, your time is limited. For most stages of the appeal process, you only have 20 days from the decision date to file your appeal, so you must act quickly. An appeal is a formal request asking a higher authority to review or reverse the decision of a lower authority. There is an established process for filing an appeal regarding workers’ compensation denials in Georgia.
To learn more about the workers’ comp appeals process here in the Peach State, contact Sherrod & Bernard, P.C., for a free initial consultation.
What Are The Most Common Reasons a Workers’ Compensation Claim Is Denied?
There are many reasons why an employer or insurance company might have denied a workers’ compensation claim. But, because of your right to appeal, an initial claim denial is not necessarily the end of the road. With that in mind, here are some common reasons for workers’ comp claim denials:
- You failed to notify your employer of your work-related injury or diagnosis within 30 days, as Georgia law requires
- You failed to file a claim for benefits within one year, as Georgia law requires
- Your condition is not work-related or did not occur while you were working
- Your condition is the result of workplace intoxication, horseplay, or some other misconduct on your part
Is There More Than One Type of Workers’ Compensation Denial?
Yes, there are two key types of workers’ compensation claim denials. One involves the outright rejection of the entire claim. When an employer or insurance provider refuses to cover any part of a claim, it effectively denies that the employee qualifies for benefits. This could be because the employee is not considered fundamentally eligible for benefits, their condition is not considered work-related, or the company does not believe the employee is hurt, for example.
The other type of workers’ comp claim denial involves denying only part of a claim. For example, the workers’ comp carrier could refuse to pay for treatment from specific providers or for certain body parts or conditions. Disputes over pre-existing conditions and non-physical injuries are common reasons for partial claim denials.
Is There More Than One Type of Workers’ Comp Appeal?
Yes, there are several stages in the workers’ comp appeals process, including:
- A Hearing with an Administrative Law Judge (ALJ) – The first appellate stage involves attending a hearing before an ALJ. The ALJ considers all evidence presented by either party and decides the resolution of the claim based on the facts.
- Appealing to the Board’s Appellate Division – If you disagree with the ALJ’s findings, you can file an appeal with the Appellate Division of the State Board of Workers’ Compensation (SBWC). You must request this secondary appeal within 20 days of receiving the ALJ’s decision.
- Appealing to a Superior Court Judge – If you disagree with the determination of the Appellate Division, your next option is to go to court. Within 20 days of receiving the Appellate Division’s decision, you can file an appeal with the Georgia Superior Court.
- Appealing to the Georgia Court of Appeals – If you disagree with the determination of the Superior Court judge, you have 20 days to take your case to the Georgia Court of Appeals.
What Are the Next Steps in the Appeals Process After a Denial?
It is essential to act quickly when you learn your claim has been denied. You have just one year from the denial to request a hearing with an ALJ and begin the appeals process with the SBWC. But, there are plenty of reasons to get started much sooner than that. The appeals process can be time-consuming, so you’ll get a resolution much earlier if you file promptly. Additionally, the evidence you rely on to support your case will only deteriorate with time, so it’s better to act while materials and memories are fresh. To begin the appeals process, you’ll need to submit a notice of claim to the SBWC. You can complete an official Form WC-14 and mail it to the address listed on the form in Section E (“Certificate of Service”). You’ll also need to send copies of the completed form to your employer and their workers’ comp insurance carrier.
What Should You Expect at a Workers’ Compensation Hearing?
Once you file your WC-14, the SBWC will proceed to schedule a hearing with an ALJ, the first stage of the appeals process. Your hearing will typically be scheduled within 60 days of when you filed the WC-14 and will take place in the county where your occupational injury occurred. The ALJ hearing will be similar to a standard trial. You will be allowed to present evidence supporting your claim to benefits. Likewise, your employer or their insurer will present evidence supporting their decision to deny your claim. Both sides may have witnesses present to testify and cross-examine witnesses from the other side. Once everyone has had the opportunity to present their case, the ALJ will consider the available facts and decide the matter. You should receive the ALJ’s findings in a letter delivered within 30 days of the hearing.
Is Mediation an Alternative to a Hearing?
In some cases, yes, mediation may be a viable alternative to an ALJ hearing. Mediation occurs when you and your employer or their insurance provider sit down with a mediator who helps to facilitate an informal solution that works for everyone. Either party can request mediation. If your case is not resolved through mediation, you can continue with the appeal process.
Talk With a Georgia Workers’ Compensation Lawyer Today
If your employer or the insurance provider has denied your claim for workers’ comp benefits, contact the Georgia workers’ compensation lawyers at Sherrod & Bernard, P.C., for a free case review. We have extensive experience helping injured workers like you seek and secure the benefits they are entitled to, so call us now.
