We at Ransom and Gilbertson are often called about denied Workers' Compensation Claims. Many of the injured workers say: "But, I was injured on the job! I have witnesses. How can they deny my claim?"
Workers' Compensation Insurance companies, like SAIF, Liberty, Sedgwick, Hartford and others, deny claims for many different reasons. The law is complicated, and IME doctors hired to exam injured workers can make the facts of your injury complicated.
Let's look at why a claim may be denied. It is important to know that there are two things a worker must prove to win when they have claim denial. First, the obvious thing we all think about: "Did the injury happen on the job." Your testimony at a workers' compensation hearing, and the testimony of your witnesses, maybe your boss and other workers will help a workers' compensation judge sort this out.
The second thing an injured worker must prove is called "medical causation." This is the tricky part. Even when you prove you were injured on the job, your claim may be denied because of "medical causation." Let's look at an example: A worker's back is injured lifting something heavy at work. There are many witnesses. The worker never had any back pain before this injury. The worker has back x-rays and an MRI, and is sent to an IME. The injury claim is denied. The denial says there is a preexisting condition. This denial is based on "medical causation." Simply put, the workers' compensation insurance company is saying you were injured on the job, but your injury is not the biggest reason for your disability and need for medical treatment.
"Medical causation" claim denials are about medical questions, like: "What do the x-rays and MRIs show?" "Did the change in symptoms mean a change in pathology?" "Was there arthritis, and did it contributed to the cause of the condition?" To get a good answer these questions you need a good doctor and a good lawyer. We at Ransom Gilbertson Martin Ratliff have helped many injured workers with claim denials based on preexisting conditions. If you have a denial, call us for a free consultation.
In our next blog post, we will discuss in detail what insurance companies and IMEs mean when they say an injured worker has a "preexisting condition."