What to Do When Workers Comp Is Denied in Florida

If you’re injured on the job in Florida, and your claim is denied by the insurance carrier, chances are you’ll be taken care of by the state’s workers compensation system. Just don’t bet your crutches or pain pills on it.

About 10% of claims are initially rejected by insurance companies. You can accept that and limp away. Or you can fight for the justice (and money) you think you deserve. Here’s a battle plan.

Appealing a Workers Comp Denial in Florida

Your employer’s insurance companies generally won’t contest minor injuries since they don’t cost much. The bigger the bills, the better the chance your claim will be disputed and maybe rejected.

It doesn’t help that insurance companies get to choose your physician. You can request a change, but the insurance company gets to select the second physician.

If you’re disappointed with the decisions of the medical and insurance professions, you might turn to the legal profession. Hiring a workers compensation lawyer is optional, but probably necessary, if you want to succeed. The appeal process for workers comp can turn into a maze. You might find it’s well worth the investment to have an experienced lawyer guide you through it.

Contact the Employee Assistance Office

The Employment Assistance Office was established to make it easier to apply for and receive workers comp benefits. The best part is it’s free. There are seven offices around the state. The EAO can also be reached at 1-800-342-1741 or online here.

The overall goal is to prevent and resolve problems between injured workers, employers and their insurance carriers. There’s no shortage of potential disputes, from benefit disagreements to recovery time to medical cost inconsistencies.

There’s also no shortage of paperwork. But the EAO will help you understand your rights and responsibilities and advise you about available services. It can also provide re-employment options and services to employees who are unable to return to work.

File a Petition for Benefits

If you decide to dispute a decision, you must file a petition with the Florida Office of Judges Compensation Claims within two years of the date of your injury.

That office will schedule a mediation conference within 40 days and notify all parties of the conference date. It must be held within 140 days of when you filed the petition. During that time, you might be asked to submit more evidence or undergo a medical exam.

Mediation

Mediation is a meeting where a neutral third party, called the mediator, will try to get you and your employer’s insurance company to reach a settlement agreement. In some cases, the insurance adjuster is also present or available by phone. The mediator is usually a retired judge or other court official.

The two sides are in separate rooms. You or your lawyer will make an opening statement that outlines your injuries, treatments, and ability to return to your job. This is where a lawyer could come in handy, since you want to make the most compelling case possible and make sure your rights are protected.

The mediator then hears what your employer has to say. He or she identifies issues that might help the parties reach a compromise and relays bargaining positions.

Most of the disputed workers comp cases are settled in mediation. If a settlement isn’t reached, a hearing is scheduled within 90 days.

Workers Comp Hearing

A workers compensation hearing is essentially a trial before an administrative law judge. You need to ask yourself whether you feel comfortable playing the role of an attorney and going up against a real attorney who will be representing your employer’s insurance company.

You’ll need to gather evidence to present to the judge. That includes medical and employment records, reports from treating doctors, photographs from the accident scene, if available, and any documentation of employer negligence.

You might also need to line up witnesses who have first-hand knowledge of the accident. As the aggrieved party, you will have to take the witness stand.

You will be questioned about your general employment and health background, the incident, medical treatment, and the prospects of returning to work.

Judges typically issue their decisions at the conclusion of the hearing. Complicated cases might take longer for a verdict, though they are usually rendered within 30 days. If both sides agree with the decision, the case is closed. If not, it’s on to the next step.

Final Appeal

The final appeal is where things can really drag out. The side disputing the decision must file its appeal within 30 days. The judge sends the case records to the First District Court of Appeal, which then receives written arguments from both sides.

The Court of Appeal will confirm the judge’s decision, overturn it or it may send the case back for more information. The process can be emotionally draining and take more than a year to play out. For better or worse, there is resolution since the decision is final.

Reasons Your Workers Comp Claim Might Be Denied in Florida

There are several reasons why a workers comp claim will be denied in Florida:

• There was a lack of evidence or witnesses.
• The application wasn’t properly completed.
• The injury was caused by a pre-existing condition not related to the job.
• The injury was not work related.
• The worker did not meet filing deadlines.
• The worker was under the influence of drugs or alcohol.
• The injury was not severe enough to warrant benefits.

How to Win a Workers Comp Case in Florida

There are a couple of general reasons people tend to lose workers comp cases. They fail to properly report their injury, or they present a case the employer’s insurance company thinks is fraudulent.

Before the dispute even begins, there are things you can do to improve your chances of success.

• Sustain a legitimate, work-related injury.
• Get prompt medical attention, and switch doctors if you think you are not getting adequate care.
• Report your injury within 30 days. This is mandatory.
• Report it to your union if you belong to one.
• Document your injury correctly and provide all details your employer or insurance agent request.
• Beware of private investigators and surveillance from your employer’s insurance company.
• Hire an attorney.

That won’t guarantee you’ll win your case. However, it will make that much more likely.