One of the benefits of living in Wisconsin is its laws expressly protect employees’ rights and livelihoods. Workers’ compensation insurance covers nearly everyone in Wisconsin.
But what happens if workers' compensation insurance denies your claim?
A moment of panic may set in. You did not ask for an on-the-job injury. Like nearly every other resident of Wisconsin, you expect workers’ compensation to cover you.
If you have gotten that letter in the mail denying your claim, no doubt, your heart sank. You might wonder how to pay the bills. And there have been plenty of bills you did not expect from doctors, specialists, and maybe even rehabilitation and physical therapy experts. Without checks coming in regularly, how are you supposed to support yourself or your family until you recover? What if your injuries permanently disable you? Let’s look at a few variables regarding the law to understand whether it covers you and your options to remedy the situation.
Who Does the Law Cover?
It's easier to say who the Workers’ Compensation Act does not cover. When it does not cover a worker, other laws may cover them.
Here are a few instances where the Act might not cover you:
Even an employer who has not paid their workers’ compensation insurance must pay for benefits if you are injured personally, and the Uninsured Employers Fund provides this.
- Post Office workers: Federal workers’ compensation laws that supersede state laws cover these employees.
- VA hospital employees: Again, because the VA is a Federal organization, they would fall under the jurisdiction of Federal compensation laws.
- Armed Forces service members: The U.S. Military has different protection, coverage, and military personnel compensation laws.
- Interstate railroad personnel: Like the Federal mandates for workers’ compensation, other laws and provisions protect railroad workers.
- Seamen and longshoremen: These services are similar to railroad and military since they often transcend state borders and are better left to protect workers of interstate trade with comprehensive laws.
- Domestic trade employees: Not a widely known workforce, domestic trade employees are exceptions to the rule.
- Persons not in the trades/business/professional occupations: These employees are hard to classify and might not have a traditional employer or workforce large enough to cover with insurance.
- Farm employees: Typically, farm employees are covered, but certain limitations such as the size of the workforce, pay, and other matters might exclude you from coverage.
- Volunteers: It stands to reason if you are unpaid, you are not an employee, but contributions also limit this (less than $10 per week).
- Religious sects: Some religious groups have fought to be exempt from these laws, and as a result, Workers’ Compensation might not cover you.
- Native American Tribal Enterprises: Unless a tribe waives its sovereignty, it is not subject to Wisconsin state laws.
The Act would cover virtually every other employee not listed above.
What Is Covered?
Your employer has an obligation to you, the employee, to harbor a safe work environment. If there are hazards associated with the job, proper training, protective equipment, and methods to prevent injury must be observed.
So what injuries does the Workers’ Compensation Act
cover?
- Physical harm: Injuries directly resulting from the nature of your work, from blunt force trauma on a construction worksite to repetitive motion injuries such as carpal tunnel syndrome or nerve damage at a desk job. A physician determines the nature of your injury.
- Mental harm: A psychologist or psychiatrist can determine psychological harm, such as post-traumatic stress disorder and other mental injuries.
- Accidental injury: You might be an innocent bystander who was caught up in something and had nothing to do with it.
- Occupational disease: Your employers should do everything in their power to protect you from a wide range of occupational diseases. Deafness, skin problems, tuberculosis, pneumonia, lead poisoning, slip and fall injuries, exhaustion, respiratory disease, hernia, back trouble, carpal tunnel, and other physical damage resulting from work may count as covered workplace injuries.
Reasons Workers’ Comp Might Deny You
Here are a few instances where an insurer would dispute coverage:
- If you are injured during a lunch break or other time off and are off-site. If you are on a smoke break, restroom break, lunch, getting water or snacks, and attending to personal needs while on the job, workers’ comp might not cover you.
- Workers’ comp will likely cover you if you are injured in a traffic accident while on the job. However, generally this would not include driving to or from work after your shift has ended.
- The insurance company may claim you were on the job but doing something of a “strictly private nature,” such as attending to a private errand or working on something that is not part of your assigned tasks.
- Workers’ compensation might not cover a self-inflicted wound or intentional self-harm.
- Workers’ comp may claim that horseplay or fighting on the job caused your injuries.
What to Do After an Injury? Document Everything
If you were injured at work, document everything.
The most likely reason for a claim denial is missing essential information.
Here is a list of what you should keep track of and tell your lawyer if you were injured.
- Dates and times: Be as precise as possible. Take pictures with your smartphone of the site of the accident as well.
- What were you doing when you were injured?: This is important because it will establish whether or not the activity is work-related.
- What caused the incident?: Be very detailed in discussing the cause of the accident. What injured you? How heavy was the object that hurt you? How big was it? Take pictures if possible.
- What are your Symptoms?: Aside from physical impacts that leave cuts, bruises, scarring, or other physical signs, traumatic brain injuries are also common. Discuss your symptoms. How long did they last? What were the treatments you received for the symptoms? Provide pictures whenever possible.
- Witnesses: You must collect information about who else saw the incident. This will help the workers' compensation insurance company ever disputes your claim.
- Who was your doctor?: You might not have gotten to pick your attending physician at the ER, but the law provides you the ability to choose your doctor for subsequent visits as long as they are certified by the State of Wisconsin. Get a complete list of all doctors involved in your treatment. This will prove crucial in any dispute.
- Cost of treatment: Compensation will need to cover your expenses. Document medical treatment, physical therapy, rehabilitation, and even artificial limbs/prosthetics.
- Dates of work lost: How much time have you lost at work? If your recovery surpasses seven days, your compensation for lost wages begins on the date of the accident, rather than waiting three days to take effect.
- Copy of written statement to the employer: Your statement to your employer establishes the date and time of the incident and that you were injured on the job.
- Agreement or final receipt for comp claim: Keep information the courts provide you since it will affect your ability to extend the claim if necessary.
The Biggest Reason for a Denied Claim
If what you say about the severity or nature of your injury goes against what your doctor’s report says, workers’ comp may deny you coverage.
Your doctor is a trained professional whose testimony is vital in continuing the claim process. You may need referrals for physical therapy, massage, pain management, etc. Your doctor must order them unless the insurer specifies they will cover them in advance. Otherwise, you might need to pay for them out of pocket.
Your employers can ask for several updates and re-examinations of your medical condition throughout the process. Be sure to comply with these requests, or else insurance companies could deny your benefits through a matter of difference in opinion between what you say and what your doctor or employers say.
Statute of Limitations
You should report your injury to your employer within 30 days of the incident. You have a time limit (statute of limitations) from the moment of the incident to make your claim. This allows for occupational diseases, which might not be so obvious or have a specific origination date, to be covered. However, the longer you take to report the incident might throw a shadow of doubt on the veracity of your claim. Your employer could simply state that you hurt yourself at home and contest your claim.
There are exceptions to this rule, however. There is often no statute of limitations in loss of limb, vision loss, permanent brain injury, partial or total knee/hip replacement.
If your reason for a denied claim has to do with the statute of limitations, a skilled attorney may shine some light on this matter and fight for your benefits.
What Is at Stake?
Your workers’ compensation benefits are essential to your recovery and maintaining your quality of life. We all depend on our jobs. If you were injured, this will affect how you go about your life, not only now but in your future. It may even hurt your family’s future.
Some benefits include:
- Payment of medical costs
- Payment for rehabilitation
- Payment for lost time at work/wages
- Prosthetic limbs
- Death benefits to surviving spouse
- Payment to surviving minor children
- Compensation to parents or close relatives you were supporting
- Burial expenses
These are all potential burdens on yourself and your surviving loved ones. Denial of a claim affects many people, and your right to be compensated is worth fighting for.
Increases and Decrease in Benefits
Employers are responsible for providing a safe work environment, and violations of those rules to protect employees have consequences. You stand to gain up to 15 percent more in benefits for employer violations. Conversely, however, you might stand to lose 15 percent for employee violations or intoxication. Document the incident so it does not become a matter of your word against theirs.
Application for a Hearing
If workers comp denied your benefits, you may dispute these findings in a hearing. You must submit paperwork to the administrative law judge (ADJ), your employer, and legal counsel. Though an appeal can take you all the way to the Wisconsin Supreme Court, this is not common. Your best shot to win your appeal comes during this hearing.
A skilled attorney will take all of your documentation, evidence, and discovery to present it in court or use it as leverage to obtain a settlement.
Contact a Workers’ Compensation Attorney Near You
If workers’ compensation denied your benefits, you need a skilled attorney to fight for your rights. Losing compensation at this critical time in your life can affect you for years to come.
Do not allow some red tape or a matter of different opinions to undermine your ability to provide for yourself and your family. Nobody asks to be injured, which is why laws protect workers and provide for them in their moments of need.
Contact a workers’ compensation attorney to learn more about fighting for your right to benefits when injured on the job.