Workers’ compensation is a mandatory benefit system. However, every injury that is reported is not automatically accepted. Workers’ compensation laws were designed to consider the interests of all parties to ensure fair and just results. The law places the reporting obligation on the employer/carrier and places the burden of proof obligation on the injured worker. If the proof or evidence of the work injury is not clear, the employer or insurance carrier may deny the workers’ compensation claim, or a benefit related to a claim.
The denial of a claim or a benefit is not the end of the road. The injured worker should know the steps necessary to pursue their claim:
1. Act promptly. The law imposes a time limit upon the reporting and requesting of claims and benefits (6 months to 6 years depending on who has or has not received notice of your claim). If you become injured, report it promptly. If you report a claim and it is denied, take follow up action promptly. Find out why it is denied and provide notice of your claim and any missing information promptly.
2. Send the department a written letter or Form 5, Employee’s Notice of Injury. The workers’ compensation division may only take action in your claim (ie. order benefits) after you have provided WRITTEN NOTICE of your claim or of the benefit you are requesting. Send your letter or Form 5 Notice to:
Workers’ Compensation Division
Vermont Department of Labor
National Life Building, Drawer 20
Montpelier, VT 05620-3401
Specify in your letter or in your Form 5 the date of your work injury, your address, your employer, and the benefit(s) you are seeking.
3. Gather evidence that supports your work injury claim. There may be disputes over how, when, or where you were injured. You need to present evidence supporting your work injury. Ask your medical providers for copies of your medical records regarding your injury. If the insurance carrier disputes that your work caused your injury, it may be helpful to ask your doctor to write a note indicating the cause of your injury or condition. If there is a question about whether your injury occurred at work, try to obtain a written statement from a witness or from someone who has knowledge of you getting injured due to your work. Make copies of the information you obtain and send the information to the insurance adjuster. If you need department involvement, send us copies as well.
4. Ask why your claim or benefit is denied. The insurance adjuster must issue a written denial of your claim within 21 days of notice of the claim and must state the reason(s) for their denial. If you do not know the status of your claim or whether it has been denied, ask. The insurance company cannot put their decision on hold indefinitely. If the reason(s) for the denial are not clear, ask. Try to determine exactly why your claim has not been accepted then try to obtain and provide the necessary information or answers to clear up the area of concern.
5. Provide missing information. Sometimes injured workers are reluctant to provide information regarding prior medical treatment, prior work or non-work activities. If the information is relevant to your claim, the insurance company is entitled to it whether you agree or not. If you are not certain if requested information is relevant, consider whether it could be “reasonably” related to your work injury claim, or call the department at 828-2286 for further guidance on relevant information.
6. Provide your medical authorization promptly. The filing of a workers’ compensation claim is a waiver of medical privilege concerning relevant medical information. Failure to sign and return a medical authorization can result in delay or denial of your claim. If the authorization appears too broad or concerns you, call the department and discuss the authorization with a member of the workers’ compensation staff.
7. Talk to your doctor and get clarification. Many workers’ compensation disputes involve medical evidence and opinions. If your claim is denied due to medical reasons, try to get more clear or additional information from your doctor, then present it to the insurance adjuster and the department.
8. Ask for an informal conference. If you have provided written notice of your claim and evidence supporting your claim and it still has not been accepted, the next step is to request an informal conference. A conference can be conducted by phone between department staff, yourself, and the insurance adjuster. The conference allows everyone an opportunity to discuss any dispute in your claim and to try to resolve differences. An informal conference is also a necessary step in the event you wish to contest any matter by proceeding to formal hearing.
9. Request a formal hearing. The workers’ compensation division is set up to encourage informal resolution of disputes. The formal hearing level remains available, however, to adjudicate issues that cannot be resolved informally. If the insurance company has denied your claim or benefit and department staff indicate that your evidence is insufficient to order payment, you may wish to ask to proceed to the formal hearing level to receive a full airing of your case. Your request for a hearing must be written, either by letter requesting a formal hearing, or by filing a Form 6 Request for Hearing.
The workers’ compensation process is designed to allow injured workers’ to represent themselves in claims for work injuries. The process can be confusing, particularly if your work injury involves disputed matters. These tips are intended to help injured workers understand what next step they can take when a claim is denied. In addition, specific questions can be answered by division staff by calling 828-2286.