When a Workers’ Compensation claim is denied, it can create a confusing and frustrating situation for injured workers. However, there still may be a way to reverse this result and obtain Workers’ Compensation benefits.
Who Decides If A Claim For Workers’ Comp. is Denied?
The Workers’ Compensation insurance carrier decides if a claim is accepted or denied. The insurance carrier is the insurance company from which an injured worker’s employer has purchased a Workers’ Compensation insurance policy.
However, while the insurance carrier chooses whether a Workers’ Compensation claim is initially accepted or denied, the NY Workers’ Compensation Board has the power to rule on if an insurance carrier’s claim denial should be upheld.
How Long Does It Take For A Workers’ Compensation Claim to Be Accepted Or Rejected?
The insurance carrier is required to file what is known as a Notice of Controversy within 25 days of receiving a Workers’ Compensation claim. Notice of Controversy refers to the formal notification that a Workers’ Compensation claim has been denied. The act of receiving a Workers’ Compensation claim is known as Notice of Indexing.
When the insurance carrier denies a Workers’ Compensation claim, the injured worker will receive a First Report of Injury (FROI) form. This form is known as FROI – 04 First Report of Injury Report Type (MTC) 04 Denial. However, if an injured worker receives FROI – 04 First Report of Injury Report Type MTC 04 Denial, this is not a final decision on if an injured worker can receive Workers’ Compensation benefits.
What Happens After A Workers’ Compensation Claim is Denied?
Following a Notice of Controversy or Workers’ Compensation claim rejection, this Notice of Controversy is sent to the NY Workers’ Compensation Board. The Workers’ Compensation Board then schedules a Pre-Hearing Conference.
The Pre-Hearing Conference Trial Process
At the pre-hearing, the court decides whether or not the injured worker has enough evidence to go forward or not with a Workers’ Compensation claim. If yes, the court gives the insurance carrier an opportunity to have an Independent Medical Exam (IME). The court then schedules a date for testimony of medical and other witnesses. The court may then direct that a written legal argument be submitted before making a decision. This process takes a few weeks.
During this Pre-Hearing Conference, both the insurance carrier and the injured worker must file necessary documents to make their case for why the Workers’ Compensation claim should be accepted or denied. This is why hiring a Workers’ Compensation lawyer early on in your claim is especially important, as the accuracy and thoroughness of Pre-Hearing Conference documents are very important as they relate to the outcome of a Workers’ Compensation claim.
Necessary Paperwork For a Pre-Hearing Conference To Decide on a Denied Workers’ Comp. Claim
An important part of these Pre-Hearing Conference documents is PH-16.2, the Pre-Hearing Conference Statement. For injured workers, the PH-16.2 Pre-Hearing Conference Statement includes the following:
- The facts and circumstances related to a Workers’ Compensation claim
- The names of relevant witnesses
- The legal theory that the case is based on
How A Pre-Hearing Conference Affects a Denied Workers’ Compensation Claim
In the Pre-Hearing Conference, after both sides of a Workers’ Compensation claim have made their arguments, a judge will decide whether a Workers’ Compensation claim should be established or denied.
Injured workers will likely be required to have an Independent Medical Exam (IME) when the insurance carrier denies their Workers’ Compensation claim. The purpose of an Independent Medical Exam (IME) is to allow the insurance carrier to get a medical evaluation of an alleged work related injury. It’s important for injured workers to provide a complete history of how a work injury happened and the consequences of the injury as part of the Independent Medical Exam (IME).
What If Your Workers’ Comp Claim is Denied At The Pre-Hearing Conference?
If a Workers’ Compensation claim is denied at a pre-hearing conference, there still may be a way for an injured worker to receive Workers’ Compensation benefits. When a pre-hearing conference decision is made, either the insurance carrier or the injured worker has 30 days from the day of the pre-hearing conference decision to file an appeal.
This appeal is then reviewed by three commissioners at the NY Workers’ Compensation Board. A decision on the appeal can take a long time. There is no established time for how long it can take for the commissioners to decide on an appeal.
At this point, the commissioners can rule to accept a Workers’ Compensation claim. However, the commissioners can also choose to deny a claim that has been appealed. This decision is not necessarily final, however. Injured workers may appeal to the Full Board at the NY Workers’ Compensation Board for a decision on a Workers’ Compensation claim. The Full Board may deny an appeal, but this decision can be appealed further to the Third Department of the New York State Supreme Court and the Court of Appeals.
Has Your Workers’ Compensation Claim Been Denied? Talk With NY Workers’ Compensation Lawyers
Whether your Workers’ Compensation claim has been denied by the insurance carrier, the NY Workers’ Compensation Board or the courts, MCV Law’s award winning NY Workers’ Compensation lawyers can help protect your rights.
To speak with our experienced NY Workers’ Compensation attorneys about your claim, contact us for a free initial consultation.