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How To Appeal A Workers Comp Denial

For salaried workers in Florida, one of the reassuring social safety nets in place is known as Workers' Compensation. It means that you may be on the job, and you get injured while working through circumstances that are not your fault. Your recovery or even rehabilitation, if an injury is permanent, is financed by workers comp money.

However, workers comp is not automatically granted upon receiving an injury. There are some cases where, after reviewing a claim for workers comp, that claim may be denied. Fortunately, this isn't the end of the story for Florida workers. It's possible to get the claim appealed. Here's how.

Step 1: Insurance Resolution


Appealing a workers' comp claim is a legal activity. Still, before you can through with it, you must first make one more attempt to resolve the dispute with the insurance company that handles your company's workers comp claims. When you are injured, you file a claim, but it is your employer's insurance company that reviews the application and decides whether to award workers comp or not.

In some cases, this may be enough. Consultation with your employers and clearing up some details with the insurance company may reveal new factors the insurance company wasn't aware of. This may result in a change of decision, and you'll get your workers comp after all.

However, if the insurance company won't budge on the decision, it's now on record that an informal attempt was made before a legal one. Now the legal approach is open to pursuit.

Step 2: File Your Claim


Once you're ready to appeal a decision formally, you need to fill out a form called the Petition of Benefits. Fill this form out and submit it to the Clerk of the Office of the Judges of Compensation Claims. This form will act as the briefing to others of your appeal, and must include information like the nature of the injury, lost wages, and other specific benefits, such as rehabilitation therapy that may be required. This form will only be accepted if it is submitted within two years of sustaining the injury. Wait too long, and the appeal can't be filed due to the statute of limitations. If this is for specific medical treatment, it must be submitted within one year of your last treatment or payment benefit.

When the form has been submitted, the OJCC will then notify the insurance company of your claim. They will then have 14 days to either change their minds and pay the workers comp or restate the denial of the request.

Step 3: Go To Appeal


If the claim is still denied at this point, the appeal will go to an OJCC district office. Your appeal will receive a case number, and you will use this to track your progress. The first step at this stage is a formal attempt at mediation.

A neutral third-party mediator will be assigned to the case, and a sit down with insurance company representatives will occur to see if this still can't be resolved. This usually happens within 130 days of your filing. If this fails, the insurance company still denies the claim, then the case is taken to the next level and is assigned to a judge. This is not like a lawsuit trial that, similar to criminal trials, involves a jury decision. Here, the judge is the sole arbiter.

Getting Help


At any stage, if you feel you need more experienced advocacy, you can always talk to an experienced workers comp lawyer about your situation. Consultations are free, and it is only if you need a lawyer's services to pursue a case that talk of fees comes in.

However, in the case of a workers' comp claim appeal, it's probably best to seek legal advice once you are at the appeal stage. It's not legally required for you to have a lawyer working with you on an appeal, but it will be a much more efficient case for you if you have someone experienced in this process working alongside you. Someone that is used to dealing with insurance companies and how they justify their denial of claim arguments will have a much better chance of dealing with a judge to show that you deserve the claim you are trying to make.