After an on-the-job injury, you should always notify your employer and file a workers’ compensation claim. The workers’ compensation law entitles you to receive financial benefits, including injury-related medical expenses, lost wages, disability payments (partial or permanent), vocational rehabilitation costs (training to learn a new skill), and claims-related expenses (such as mileage). If an employee suffers a fatal injury at work, workers’ compensation also pays death benefits to his or her dependents.
In most cases, you have just 90 days from the date of your injury to seek care from an employer-approved health care provider and to file a workers’ compensation claim. However, even when you follow the rules and make a timely claim, the workers’ comp provider (usually an insurance company, self-insured employer, or managed care organization, or MCO) may still refuse to pay you the benefits you deserve. What then? Read on to find out.
Appealing a Denied Workers’ Compensation Claim
Contact a workers’ compensation attorney right away if you receive a letter denying your workers’ compensation claim. A claim denial forces you into a dilemma in which receiving the benefits you deserve may require facing off against a powerful organization—the workers’ compensation carrier—determined to cheat you out of what you deserve. It is always in your best interest to hire experienced, aggressive legal counsel to fight back. You cannot win that battle on your own.
Under Nevada law, you have 70 days from the date of the denial to appeal the decision to the Nevada Department of Administration (DOA). This is a firm deadline. Failing to file an appeal within 70 days, in most cases, means the automatic and irreversible loss of your rights.
The workers’ compensation appeals process involves two successive stages, both of which involve the DOA: a Hearing Officer review, followed by an Appeals Officer review. If those appeals fail, you may pursue your case further in Nevada state civil court. Here is a description of each appeal step.
Hearing Officer Review
The first step in appealing a workers’ compensation claim denial is a hearing before a Hearing Officer in the DOA at the DOA’s Carson City or Las Vegas office, scheduled within 30 days of you having filed your appeal. A hearing is like a trial in court, only much less formal. Instead of a judge, the Hearing Officer presides over the hearing. The parties (you and the insurance company in most cases) attend. Before the hearing, each party can submit evidence for review by the Hearing Officer.
At the hearing, each side gets an opportunity to present its arguments and evidence. The Hearing Officer then decides either that you should receive benefits or that you should not. If you disagree with the Hearing Officer’s decision, then you can request a further review by an Appeals Officer.
Appeals Officer Review
Within 30 days of the Hearing Officer’s decision to uphold the denial of your workers’ compensation claim, you may request a hearing in front of an Appeals Officer. This hearing covers the same ground as the Hearing Officer’s review, but is more formal than the previous stage. Everything that occurs at an Appeal Officer Review is recorded for an official transcript. The Appeal Office reviews the evidence anew, which means you can’t rely on anything that happened at the Hearing Officer review or on the evidence you submitted before or during it. Instead, must submit your evidence and make your arguments all over again.
The Appeal Officer decides whether to affirm or revise the Hearing Officer’s decision. If you are unsatisfied with the decision, then you may appeal your claim in Nevada courts.
Appealing to the Court
Within 30 days to appeal the Appeal Officer review decision, you may file an appeal in the form of a legal action in the civil division of the Nevada District Court. This stage of the appeal process is even more formal than the previous one. It is a full-blown lawsuit that requires you to comply with intricate rules of procedure. If you didn’t have an experienced attorney by your side throughout the earlier stages of appeal (and, to be clear, you absolutely should have), then you cannot go without an attorney at this stage.
Dealing With Managed Care Organizations
While many companies use an insurance company or are self-insured for their workers’ compensation insurance, some choose to contract with a managed care organization (MCO). MCOs provide employees a network of approved health care providers to treat work-related injuries. The process for handling a workers’ compensation claim differs slightly with an MCO from dealing with an insurance company or self-insured employer.
Under Nevada law, MCOs and injured employees are required to attempt to solve disputes informally before going through the DOA appeals process. Employees who disagree with a coverage decision made by an MCO must provide written notice to the MCO within 14 days of the disputed decision. Then the MCO has 14 days to respond to your letter. If you find the response of the MCO unsatisfactory, at that time you may request a hearing before an Appeals Officer within 30 days of the MCO’s response. This means that you skip the steps of requesting and going through a Hearing Officer review and move right to an Appeals Officer review.
You may still appeal to the District Court if you are then unhappy with the result of your Appeals Officer review.
A Workers’ Compensation Attorney Can Help You
If there is one clear message we want to send about workers’ compensation appeals, it is this: you need an experienced workers’ comp attorney by your side every step of the way.
Errors at the earliest stages of an appeal can doom you later on down the road.
Do not risk your financial and physical health by trying to appeal a workers’ compensation claim denial on your own.
Benson & Bingham Accident Injury Lawyers, LLC
626 S 10th St
Las Vegas, NV 89101