It is a sad truth that sometimes deserving compensation claims are denied. The insurance company sends you a Notice of Insurer’s Primary Liability Determination form saying that they won’t cover you, and you are left with your bills and no help.
Fortunately, there are avenues to explore when this happens. So here is the process for when you need that compensation, but the insurance company decides otherwise.
Your First Steps
When you first get the Notice from your insurance company, call your claims adjuster. Make sure you write down the date, time and adjuster’s name. In the best case scenario, the adjuster says, “Oh, it was a mistake. We’re working on approving your claim now.” Of course, that scenario is unlikely.
If the adjuster fails to fix your problem, you can appeal the denial by filling out an Employee’s Claim Petition, found on the Department of Labor’s website. Include a doctor’s report supporting your claim, and send it to the Department of Labor’s workers’ compensation division. Getting a lawyer to help fill out the claim and advise you on how to proceed is a good idea here. Send copies of your petition to your insurer and your employer.
What Will The Department of Labor Do?
If the case is simple and all the information is present in the petition, the DLI will issue a Decision and Order. If it’s more complicated, the department will schedule an administrative conference. The department will provide a mediator who will encourage everyone to come to an agreement, but if the parties can’t agree, the mediator makes a Decision and Order for them.
You have a right to have a lawyer help you with the conference, and you will probably also need a lawyer if your case goes to the Office of Administrative Hearings for a settlement conference. The DLI will sometimes send cases to the OAH directly if the case doesn’t involve medical or rehabilitation claims, or is complex.
When people disagree on a worker’s compensation case and the case is complicated, they can request for the OAH to arrange a settlement conference. At the conference, you and your representative can present a proposal along with documentation for you to receive benefits, and the insurers and their representative bring their own documentation.
The hope for these conferences is that all the parties come to an agreement about your case. You don’t have to enter into a settlement on any of your benefits to receive them, but it will likely be practical to do so. When you and the insurer reach an agreement, the parties will have it written out in a form called a Stipulation for Settlement, which will cover the facts of the case, the insurer’s and yours positions, and the decisions the parties agree to.
The OAH must receive the Stipulation for Settlement within 45 days. To make sure that happens, the OAH arranges for a second conference, called a Stipulation Status Conference. This conference will cover anything that the parties need to do in order to get the Stipulation for Settlement entered. If the paperwork is already filed, this conference is cancelled.
After the Settlement?
The compensation judge who receives your Stipulation for Settlement form will issue an order called an Award on Stipulation to approve the settlement. This is where it really helps to have legal representation: the judge is much more likely to automatically approve your settlement if both parties have lawyers (and you can bet that an insurance company will have a stable of them.) If you don’t have a lawyer, your settlement needs the official approval of a compensation judge or the Commissioner of the Department of Labor.
If the conferences fail to bring agreement or the parties don’t request mediation, an OAH judge will conduct a hearing on your case. The judge will hear evidence, witness testimony and expert testimony. Depending on the amount of testimony and evidence, the hearing can take anywhere from a day to several weeks. The judge will issue a written decision within 30 to 60 day after the hearing.
What If The Settlement Falls Apart Or The Award On Stipulation Is Rubbish?
Compensation judges make mistakes and settlements fall apart. If you reach the Stipulation Status Conference and none of the parties can agree on things, the judge or mediator will offer resources to help resolve the differences. However, if one or the other party backs out of the agreement entirely, the OAH will put it on the trial calendar for a compensation judge to hear.
If your mediator makes a decision you disagree with at the DLI’s administrative conference, you and your lawyer can fill out a Request for a Formal Hearing.
If there is a change in your condition or the order is mistaken, you can appeal this decision to the Workers’ Compensation Court of Appeals. This is a court of 5 judges that review decisions on workers’ compensation claims and changes them when necessary. You will only be able to argue why the original order was wrong, though, not retry your case.
The decisions of the WCCA can be appealed to the Minnesota Supreme Court within 60 days of their hearing.
The appeals process gets intricate and requires a lot of expertise, so if your claim gets denied, contact us. We will help you out.