Appealing a Denied Workers’ Compensation Claim

Appealing a Denied Workers’ Compensation Claim

Since 2013, the initial workers’ compensation claim denial rate, which was already high, has increased by 20%. Many Claims Examiners deny claims for technical reasons, such as a failure to submit the claim before the deadline. Other Claims Examiners deny claims based on legal defenses, like horseplay or a failed drug test, even though they are not lawyers and they are not qualified to make such decisions.

Fundamentally, however, most Claims Examiners deny most job injury claims because these victims have no advocate at this level. Things are much different after a Chicago workers’ compensation lawyer gets involved. At the appeal stage, an attorney works hard to obtain the financial benefits that injured workers need, not the benefits an insurance company adjuster offers.

Preparing an Appeal

These benefits usually include lost wage replacement and medical bill payment. Generally, these benefits are no-fault benefits, which means injured workers need not prove fault or negligence. However, some defenses could apply, which is why it’s so important for a Chicago workers’ compensation lawyer to thoroughly prepare an appeal.

Workers’ compensation benefits are usually unavailable if the victim fails a drug test or refuses to take a drug test. 

These results are only admissible in a workers’ compensation claim if the test met certain requirements and the sample was handled in a certain way. Attorneys are often able to exclude test results on technical grounds.

Additionally, despite what insurance adjusters claim, there is a big difference between a failure to take a test and a refusal to take a test. If a job injury victim had a legitimate reason for missing a scheduled drug test, the victim usually gets at least one do-over. After all, the purpose of this testing requirement is to ensure that deserving applicants get benefits, not to deny benefits to deserving applicants.

We also mentioned the horseplay defense earlier. Generally, this defense only holds up in court if the injury occurred during horseplay that was completely unrelated to job activity.

Assume Harry fell and broke his arm while he and Sally were racing to see who could clean up their work areas first. That’s horseplay, but not horseplay that is completely unrelated to a job function.

Similarly, many claims get denied because the injury was not work-related. Illinois law defines this phrase broadly in this context. Employer benefit is key.

Assume Jerry broke his leg during a company softball game. His injury is job-related under state law. Jerry’s boss benefited from the game, not only because of the free advertising but also because happy and healthy employees are usually more productive and less costly employees.

A Workers’ Compensation Appeal

Administrative Law Judges usually hear workers’ compensation appeals in Illinois. Much like an elected or appointed judge, an ALJ considers legal arguments and rules on evidence issues. Therefore, an Illinois workers’ compensation lawyer has a very good chance of winning an ALJ hearing.

Insurance companies know the odds are against them. Therefore, they are usually willing to settle these cases on victim-friendly terms before the matter goes to an ALJ hearing.

Reach Out to a Hard-Working Cook County Attorney

Job bias victims have legal options in Illinois. For a free consultation with an experienced Illinois workers’ compensation attorney, contact the Law Office of Mitchell A. Kline. After-hours and virtual consultations are available.