A claim is usually started by an injured worker’s visit to a doctor or emergency room. An 827 form is completed. It can also be started with an 801 form filled out by the worker and employer. A claim can be for an injury or for an occupational disease. Some employers are covered by SAIF or another insurance company. Some are self-insured.
Some workers have trouble getting their claim started because the employer will not give them the 801 form. They should know that 801 forms are not necessary and a claim can be started with a letter containing the basic facts about the injury or disease sent to the employer and/or insurance company. Sending it to the insurance company or claims processor by certified mail is probably the best route. (Claim documents are often “lost” by employers.) A better thing to do is for the worker to get an attorney’s help.
The insurer or employer has 60 days to either accept or deny the claim (from when they receive it). Sometimes they will accept a claim but not accept the correct medical condition. For example, if a worker has a broken ankle, the insurer might accept a “contusion” or “strain.”
If the claim is denied, the company sends a denial letter to the worker and the deadline to appeal starts running. The deadline is 60 calendar days from the date on the letter, regardless of when it was received by the worker. Sometimes 60 days is less than two months. (For example 60 days from July 1 is August 30, not September 1).
Denials should be appealed by a professional. Anyone receiving a denial should get help from a workers’ compensation attorney as soon as possible—well before the 60 days expire. Important rights can be lost if this is not done correctly.
There are many reasons an insurer might deny a claim. Sometimes they do not believe the worker’s account of what happened. Often it is due to medical issues. These are very complicated and, even if they want to help, doctors usually do not know what to say. Workers with these issues need assistance from an experienced attorney.
When a denial is appealed, a hearing date is scheduled with a workers’ compensation judge. If the case has merit, the attorney will prepare evidence by working with the client’s doctor(s) and/or witnesses and the client.
After the record is closed for the hearing, the judge has 30 days to issue a written decision. This decision can be appealed to the Workers' Compensation Board, which has “de novo” review—meaning they can take a fresh look at most aspects of the case. They usually do not allow additional evidence to be offered at that point, though. There is no time limit on the Board’s review process. Board decisions can be further contested at the Court of Appeals.