insurance carrier

When a Work Injury Claim is Denied

Sthethoscope and medical documentsSometimes a work injury claim is denied by the worker’s compensation insurance carrier. The Indiana law indicates that no compensation is allowed for an injury or death due to an employee:

  • Knowingly self-inflicting the injury or death;
  • Being intoxicated at the time of accident which is proximate cause of the injury;
  • Committing an offense which led to the injury;
  • Knowingly failing to use safety equipment or apparatus;
  • Knowingly failing to obey a reasonably written or printed rule of the employer which was posted in an obvious place;
  • Knowingly failing to perform an official duty of the job which directly led to the injury.

However, it is the employer’s responsibility to prove that such behavior on the part of the employee resulted in his or her work injury. If the employer is able to prove such, then the injured worker is barred from any compensation for his or her work injury.

In other cases, an injured worker’s claim may be denied for reasons that are not so clear. Regardless of the circumstances, all injured workers should receive written notification from the employer if their claim is being denied approximately thirty (30) days after the employer is first made aware of the work accident and injury(s).

Filing a Claim With the Worker’s Compensation Board of Indiana

If a claim is denied, the employer or the worker’s compensation insurance carrier must let the employee as well as the Board know through a written form called a Report of Claim Status/Request for Independent Medical Examination (Form 38911) within thirty (30) days of the employer’s knowledge of the accident.

Thereafter, the injured worker has the right to file a claim on his or her own with the Board, but this must be done within two (2) years from the date of the work accident.

To file a claim, the injured worker must complete and send to the Board an Application for Adjustment of Claim (Form 29109). The injured worker may also want to contact an Ombudsman at the Board for further information about this application.

Medical Treatment

Medical treatment will be on your own if worker’s compensation denies your work injury claim. Your options are to:

  1. Pay out of your own pocket, OR
  2. File with private health insurance.

Keep accurate records of the expenses your accumulate for treatment related to your work injury because this information will be needed if you contest the denial of your claim. If you do contest the fact that your claim was denied by your employer’s insurance carrier, and you file an Application for Adjustment of Claim with the Board, then medical providers who have provided treatment for your work injury cannot try to collect payment from you until it is determined who – either you or your employer’s insurance carrier – is responsible to pay.

In order for medical providers to be considered for payment when the Board determines who is responsible to pay for your medical treatment, the provider should file an Application for Adjustment of Claim for Provider Fee (Form 18487) with the Board.

This rule only applies to those who treat you for the work injury. So, if your credit card company is coming after you for not making the required payments, even if the reason you cannot make these payments is because you are not working now as a result of your work accident, you will not be protected by your worker’s compensation case. Similarly, if you have a collector calling you about a dental bill that is unrelated to your work accident, there is nothing you can do about it through your worker’s compensation case.

Have a question about a denied worker’s compensation claim? Call us at 317.569.9644 for a free consultation to see how we can help.

Giving a Recorded Statement

It is not unusual for an insurance adjuster to ask the injured worker, or a witness, for permission to take a recorded statement. A request to take such a statement does not mean the claim will or will not be accepted. Likewise, you do not have to agree to give a recorded statement in order to receive worker’s compensation benefits.

The statement will likely be taken before any decision is made with regard to the injury claim. It is done as part of the insurance carrier’s investigation into the incident.

If you do give a statement, the questions that will be asked may include questions about your job, how the accident occurred, if you had prior medical problems and so forth. Here are some suggestions to follow if you are giving a recorded statement:

  1. Be honest and truthful. This statement may be used against you later on (if you are dishonest).
  2. Do not guess. If you do not know the answer, say that you do not know or do not recall. Otherwise, you will be held to your answer.
  3. You only have to answer the question. You do not have to give more information than asked for.

Before giving a recorded statement, it is wise to have an outline ready with the facts of your claim. Go over the details of the accident and the events that led up to it. You can also note the effects it’s had on your life and the treatment you’ve received up to this point. This will keep you on track during the statement. Remember to stick to the facts, do not stray.

If you’d like the advice and guidance of an attorney before giving a recorded statement, contact the attorneys at Klezmer Maudlin at 317.569.9644.

Have you experienced lack of due diligence by your adjuster or employer?

Under the Indiana Workers’ Compensation Act, employees can receive financial penalties against an insurance company or an employer who acts with a lack of due diligence.  The definition of lack of due diligence is likely what the judge thinks is unreasonably slow.  They are expected to handle claims with persistence, attentiveness and in good trust.

Insurance adjuster’s are oftentimes overworked and not responsive.  Not only do you experience this, but we also deal with unresponsive adjusters on a daily basis.  There are many good adjusters also, but many adjusters have too much work resulting in unreturned emails or unanswered phone calls, and therefore unable to perform effectively.  Such conduct could result in a judge penalizing the insurance company for a lack of due diligence.

In our office’s experience, to obtain an award of financial penalties for lack of due diligence requires the injured worker and/or his attorney to keep documentation of each and every step along the case that the adjuster/employer does not act responsibly and within a reasonable amount of time.  If you feel that your claim involves one for lack of due diligence, please remember that the Workers’ Compensation Act allows the judge to penalize the slow party and award you money for their lack of due diligence.