My Claim for Benefits Was Denied. How Do I Contest a Bad Decision Made by My Insurance Adjuster?

After an insurance carrier denies a claim for benefits they will file a Notice of Controversion, which is a form that states the reasons why the claim has been denied. In DC, insurance companies are not obligated to pay workers’ compensation benefits initially, and there’s no initial award or award order entered. They can voluntarily pay benefits if they believe it is a compensable claim. However, they can also stop paying these benefits at any time for any reason unless you obtain a Compensation Order to force a carrier (insurance company) to pay your benefits.

Two ways that you can contest a Notice of Controversion are by filing for informal conference or formal hearing.

An informal conference is essentially an attempt to resolve issues informally, meaning no court reporter, or witnesses, no testimony taken under oath. An informal conference is a mediation with a claims examiner who will issue a recommendation within 30 days of the conference date. The claims examiner will attempt to resolve the issue amicably, or encourage the parties to do so. If that’s not possible, the claims examiner will issue a memorandum of informal conference or a non-binding recommendation.

While a lot of lawyers will request an informal conference after their client’s claim is denied, that’s not how we like to do it. We take the more aggressive approach and often go straight to a formal hearing.

Here’s why we do this:

If you can’t work due to your injury and aren’t getting paid or compensated by your employer, it can be extremely frustrating dealing with the slow workers' compensation system. It can take months to get a hearing date and even after the hearing it can take more months to get a decision.

An informal conference recommendation is not binding on the parties; so even if you win, legally they don’t have to pay your benefits.  All they have to do is request a formal hearing. And you just lost 3 or 4 months where you weren’t getting paid.

That’s why we go straight to a formal hearing. In formal hearing discovery is required (which is a legal term for full disclosure) and at the end of the process, whatever the judge decides is binding. This means that if you win the formal hearing, the insurance company will be legally required to pay your benefits. The insurance company ha

There are other reasons but that’s the main one.  Plus, a formal hearing decision is binding – it adds pressure to insurance companies to pay you because even if they appeal the Formal Hearing decision, the employer and insurance carrier must pay the benefits while the case is on appeal.

There are many different factors that can either help you get your workers comp benefits earlier or delay your process. And insurance companies, who have dealt with thousands of workers compensation cases like yours, know all of the tricks and tactics to lower their costs by denying your benefits.

Want more information on how to fight this unfair battle? Order Protect Your Rights: The Ultimate Guide to DC Workers’ Compensation by clicking here or call us today at (202)393-3320 to order this guide. This book has tons of information about how to deal with a workers’ compensation case and what your rights are as an injured worker.

And we’re providing it to injured workers in the DC metro area for absolutely no cost or obligation. Call today while supplies last.

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