Employers will use every tactic at their disposal to deny a workers’ compensation claim, and all too often they succeed. The moment a denial comes in, it is tempting for a worker to feel disheartened or to give up or pursuing their claim. With the assistance of workers’ compensation attorneys in Las Vegas, workers can appeal their denial to the Nevada Department of Administrations and reopen their claim.
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Appealing a decision protects workers from insurance companies that would otherwise deny every claim, and never compensate injured workers. Though the process can seem long and complicated, the process is really just a simple three stage procedure: analysis, filing, and hearing.
Analysis Of Workers’ Compensation Denial
Workers’ compensation attorneys in Las Vegas begin their analysis of an appeal with a look at why the insurer denied the claim. Nevada recognizes four typical reasons for a denial of compensation.
- Improper Filing: The single biggest reason for denial of a workers’ compensation claim is a mistake made in the filing of the claim. To qualify for workers’ compensation, the claim must be made within the specified time period, and include all of the necessary medical documents and personal statements. If the file was incomplete in any way upon filing, the insurer has grounds for denial.
- Employee Misconduct: An employee who was negligent at work, either misusing equipment or engaging in horseplay, is almost immediately disqualified from compensation. Workers’ compensation attorneys in Las Vegas do have some wiggle room defining employee misconduct and may be able to convince a review board the conduct in question was condoned or encouraged by the employer.
- Injury Outside of Job Duties: An injury that occurs when engaged in activities unrelated to the job, such as a sprained ankle at a company softball game, may be grounds for denial in the eyes of the insurer. Fortunately, workers’ compensation attorneys in Las Vegas can use Nevada laws that extend workers’ compensation protection to many company sponsored or required events.
- Employer Dispute of a Fraudulent Claim: To avoid paying a workers’ compensation claim, the employer can make the argument that the injury is either non-existent or occurred when the employee was not at work. Employers strengthen their case by claiming the employee notified the employer of the injury after the window of notification closed.
Some other justifications do exist, but they are either rare or can be more broadly applied to one of the four primary categories.
Filing Appeal Paperwork
After a worker receives a letter of denial from the insurer, he or she has 70 days to make an appeal to the Nevada Department of Administrations, or DOA. The DOA requires employees to file a Request for Hearing form, which must be sent to the DOA office, along with the denial letter.
Once the DOA receives the paperwork, they will work with workers’ compensation attorneys in Las Vegas and the insurance company to schedule an appeal hearing.
Hearing Before The DOA
In the appeal process, employees have three levels in which to make their case. The claim must go through all three levels in order, if the employee is to move through the process.
- Hearing Officer: The first level is with a Hearing Officer at the DOA. In most cases the mood is informal, and nothing said goes on an official record. The officer reviews all of the evidence in the hearing request, along with the denial letter. Then, the officer brings representatives from both parties to make oral arguments about the case. The procedure does not take long, and decisions are often handed down the same day.
- Appeals Officer: In the event the decision went against the employee, they may escalate their claim to the next level with a Request for Hearing Before Appeals Officer. The employee has 30 days to make the appeal after meeting with the hearing officer. This time, the proceeding is formal and everything said is put on record. Both sides must present all evidence to the Appeals Officer, who will take time to review the case. The decision may take several days.
- Civil Court: The last stage of appeal is to take the case to civil court. A Petition for Judicial Review must be filed no later than 30 days after the Appeals Officer makes a ruling. Because the Petition for Judicial Review is a legal matter, employees need workers’ compensation attorneys in Las Vegas to take care of the paperwork and satisfy the court’s requirements.
If an employee is unsatisfied with the civil court’s decision, there are few options left to pursue.
Denial of a workers’ compensation claim should not be seen as the end of the fight, but a starting point to move forward. Insurers deny many claims that come across their desks, but a neutral third-party reviewer can reverse the decision.
