Wilmington Workers’ Compensation Lawyers

Appeals for Workers’ Compensation Benefits

Workers’ Compensation has several important functions. It can be defined as accident insurance that companies pay to cover employees that are injured on the job. Benefits include lost wages, temporary or permanent disability, and medical care. If the worker suffers a fatal injury, the benefits get paid to that worker’s family. As such, this insurance can protect both workers and employers.

There are state Workers’ Compensation funds that provide for private companies, and federal Workers’ Compensation that provides for government workers. In Delaware, companies that have at least one employee are mandated to provide Workers’ Compensation, with some exceptions, including domestic workers and farm laborers.

When Workers’ Compensation Claims are Denied

For some injured employees, the Workers’ Compensation claims process does not go as smoothly as they hope, and their claims get denied. In other cases, the employer and employee do not agree on the amount of benefits. In both instances, the insurance company needs to explain the reason for denial. When either of these situations occur, the employee has the option of filing an appeal.

Why are these claims challenged or denied? If an employee is injured at work and does not take certain steps when making the claim, questions about its legitimacy may be raised.

When circumstances pertaining to the accident are not documented, the employer and their insurance company might feel that it is not legitimate. They could also feel that the employee was not following safety protocols, had a preexisting injury, or was intoxicated at the time. They could say that the employee was not even on duty or was horsing around on the jobsite when the accident occurred.

Most Workers’ Compensation claims are investigated carefully, since more claims equal higher insurance premiums for the companies. This is the reason why denials are not uncommon.

Sometimes, insurance companies deny initial claims in order to see if the claimant will drop it. Either way, the denial should be appealed; that rejection does not always mean that the worker is not eligible for benefits.

The First Appeal

Employees that receive denials or cannot reach an agreeable claim with employers should contact the Delaware Office of Workers’ Compensation for assistance with filing a Petition to Determine Compensation Due. If the petition is sent in the mail it is best to do it certified, with a return receipt.

There is a time limit of two years after the injury has taken place; for occupational disease claims, the limit is one year after the condition became apparent.

To help with the claim, the employee should have

Physician reports
Information about any witnesses
A statement about the benefits sought
A copy of the insurance company’s denial letter

These requirements are described in a pre-trial memo, which is sent to both parties. The employee and employer are both required to prepare pre-trial paperwork and go to a pre-trial conference.

The cases are then presented at a hearing with the Industrial Affairs Board (IAB). This occurs within 120 days after the pre-trial scheduling conference’s notice date. At the hearing, both parties may question witnesses and present evidence. Afterwards, the IAB will either deny or approve the claim, in writing.

The Second Appeal

If the IAB appeal is denied, the employee and company might both have a chance for a second appeal. This must be made within 30 days to the county Superior Court where the injury happened.

Although superior court does not hold a second hearing, they will review the IAB’s hearing. They may decide to send the claim back to the IAB for additional review, reverse the claim, or both.

Final Appeal

If the claim is denied, though, the employee has 30 more days to contact the State Superior Court about the case.

Once the State Superior Court makes a decision, it is final. Since Workers’ Compensation claim denials are complex and can be quite stressful, having sound legal guidance is beneficial.

An experienced Wilmington workplace injury lawyer at McCann Dillon Jaffe & Lamb, LLC that specializes in Workers’ Compensation denials can help injured workers get the benefits they are entitled to.