Four Possible Reasons Your D.C. Workers Compensation Case Was Denied

| Frank R. Kearney |

Although workers’ compensation in Washington, D.C. was originally designed to benefit the worker, it does not always work out that way. Instead, the workers’ compensation system is complex and adversarial. It often does not favor the worker and requires that they fight the workers’ comp insurance company to get the benefits they need. As an employee, you must be ready to present your case to a specialized D.C. administrative law judge. Even after you go before a judge, your claim might still be denied, leaving you to deal with the injury alone.

The passionate workers’ compensation attorneys at Donahoe Kearney are here to help ensure you file your Washington, D.C. claim correctly. Our law firm will help you gather the evidence necessary to present your case in the best light possible. In many situations, presenting the right evidence can mean the difference between a fully compensated work injury and an outright claim denial.

If you are facing a denied claim or you are concerned your claim will eventually be denied, you may need a workers’ compensation attorney to help. Below are the four common reasons that claims are denied in Washington, D.C. Knowing and understanding these reasons can help you present your case in a way that increases the odds of receiving the workers’ compensation benefits you deserve.

Am I Eligible to Receive Workers’ Compensation Benefits?

Before submitting a claim, you first need to consider whether you are a worker who is eligible to receive workers’ compensation benefits. Not every worker can get benefits, and not every injury or accident will trigger benefits.

If you are not eligible to receive benefits, your claim might get denied right away for that reason. Consider the answers to the following questions before you file for workers’ compensation in Washington, D.C.

Were You Hurt in Washington, D.C. or Regularly Work in D.C.?

Only D.C. workers will qualify to receive D.C. workers’ compensation benefits. Although this general concept may seem straightforward, it may be much more complicated than you might think.

To qualify for benefits in Washington, D.C., your employer must either have a physical location in D.C. where you work or send you to D.C. to perform work activities on a regular basis. You must also be a private-sector employee, but any occupation, such as a plumber, electrician, construction worker, waiter, retail worker, office workers, bus driver, etc. will qualify. Employees who work for D.C. or the federal government must use a different method to address work injuries.

Was Your Injury Work Related?

The District of Columbia Workers’ Compensation Act requires that all work injuries “arise out of and in the course of employment” to qualify for benefits. This phrase may seem simple, but an entire line of case law has developed in Washington, D.C., to address this phrase alone.

In general, there must be some link between the reason the injury occurred and the work that you were performing. That is, an employee must have been furthering the employer’s business goals when the injury took place. However, many exceptions exist to undermine this rule, including the following examples.

Going to and from work

Although you are definitely benefiting your employer by going to work, you generally cannot claim a work injury for your daily commute. This is referred to as the “going and coming rule.” There are exceptions to this rule, as well. For instance, if the employer paid for your transportation, you are on the clock, or you are driving a company vehicle, the injury might be considered work-related.

Horseplay

Workers’ compensation is generally a no-fault system, so fault is not considered at all. There are a few exceptions to this rule, including some situations involving horseplay or goofing around when the injury occurred, but they are rare. These cases are extremely fact-intensive and might depend on the severity of the conduct and the resulting injury.

Breaks and Lunch Periods

In most situations, injuries that occur over a break or lunch period will be compensable. However, these injuries are also closely scrutinized. They are more likely to be compensable if the employee was on the employer’s premises when the injury occurred.

In some cases, determining whether your injury was work-related can be very simple. In other situations, it might be complicated enough that you will need a medical expert to provide their opinion about what caused the injury so that the Office of Workers Compensation can determine whether it was related to work. For instance, if your injury was due to repetitive motion or occurred over time, you will need medical evidence that relates your injury or illness to the work activity.

Keep in mind that D.C. workers’ compensation law also provides compensation for the aggravation of a pre-existing condition. As a result, you should still qualify for workers’ comp benefits to address the extent of the aggravation.

Are You an Employee?

Only employees can receive workers’ compensation benefits. Examples of workers that are likely not considered employees include:

  • Casual workers
  • Independent contractors
  • Subcontractors
  • Gig workers
  • Volunteers

In addition, your employer must also be an employer required to provide workers’ compensation insurance coverage under Washington, D.C. law. Most employers are required to carry this type of insurance, but there are some exceptions.

What Are Some Common Reasons Why Your Workers’ Comp Claim Can Be Denied?

Insurance policy denial

The workers’ compensation system requires that you meet a lot of specific requirements to get benefits and remember your employer or workers comp insurance company can deny a claim for any reason in D.C. If you do not get the specific evidence you need, your claim might be denied. Certain unique facts of your case might also trigger an employer to issue a workers’ comp denial.

Failure to Report the Injury Within the Timeframe

You must report the injury to your employer to receive workers’ compensation benefits. Failure to report can result in an outright denial of your claim. As a result, it is absolutely critical that you report your injury to a supervisor, foreman, or the HR Department as soon as possible after your injury.

As part of your report, you need to explicitly state that your injury occurred at work. It is not enough to say that your back is hurting or your shoulder is sore — you need to include what caused that injury. Including a description of what you were doing when the injury occurred may be a good idea to clarify that this is a work-related injury. In addition, list any witnesses to the accident.

The reporting time limit for workers’ compensation in Washington, D.C. is 30 days. This reporting requirement applies even if someone else witnessed your injury. While you do not have to provide written notice, it might be a good idea. A written report will provide something you can point to that will show you provided timely notice. Be sure to keep a copy of the written report for your file as well. Keep any text messages or emails you send that discuss the injury, too.

Lack of Supporting Medical Records

Your medical records tell the story of your injury. They document the incident report you provided to a medical professional about the incident, and they document the follow-up care you received.

The initial report to a medical provider is often seen as more credible than any other type of report. Most people visiting a medical professional will be truthful in the description of their accident because they want the doctor or nurse to have the best information possible to provide adequate and appropriate care. Do not make the mistake of just saying your back hurts — if you hurt your back at work, tell the doctor exactly that.

In addition, pursuing follow-up medical care shows that you have an interest in bettering your health and returning to work. Expert opinions regarding causation and how your workplace accident will affect you in the future explain the seriousness of the damage to a judge.

Many workers’ compensation claims end up being denied because of a lack of medical records. The claimant might not go to the doctor or decline to have follow-up medical treatment. These actions tend to show that the worker does not think their injury is serious or worth attention. Even if you should be entitled to benefits, this lack of documentation can result in having your workers’ compensation claim denied.

Unexplained or Pre-Existing Conditions

Workers’ compensation coverage in D.C. requires that an employer pay for aggravating a pre-existing condition. However, the employer is not required to pay for care related to the full condition—just the difference in the condition before and after the workplace injury.

If you already have the same injury or condition before the work accident as you do after the accident, that can trigger a denial. You need to show that your employment caused the accident, and that your pre-existing condition was aggravated, not just that you have a continuation of the same prior injury or you are not sure why the injury exists.

Employer Disputes Your Claim

In some situations, the employer might dispute your eligibility to receive benefits. They might dispute it because they do not think the injury occurred at work or was related to your job. They might also assert that you were intoxicated at work, engaged in horseplay, or not eligible for benefits at the time the work injury occurred.

What Should You Do If Your Workers’ Comp Claim is Denied?

Attorneys sitting around a table working

Unfortunately, workers’ comp insurance companies deny legitimate claims on a regular basis. These insurance companies know that a certain percentage of people will just accept their decision and will not do anything else. In other situations, the injured worker does not understand the process and will not act in time to fight back against the insurance company.

If your claim is denied, you need to take action and start the appeal process.

A Formal Hearing

Gather all the evidence you can that you reported the claim, such as letters, photographs, or emails. Be sure that you have proper medical evidence, including doctor’s reports that show the injury happened at work and that you cannot return to your regular job because of the work injury. All of this will be helpful as you work through the formal hearing process.

A formal hearing is similar to a full trial proceeding. You will work with your workers’ compensation attorney to present evidence and examine witnesses before an Administrative Law Judge.

File a Review with the Compensation Review Board

If you are unhappy with the opinion from the formal hearing (called a Compensation Order), then you can request a review with the Compensation Review Board. A panel of judges will review your case and issue another decision.

Appeal with the D.C. Court of Appeals

The final step in the appeal process is with the D.C. Court of Appeals. You must file with the Court of Appeals within 30 days of the CRB judgment if it is not in your favor.

How Long Will a Workers’ Compensation Appeal Take in Washington, D.C.?

The appeal process can be lengthy and will depend on how far you must take the appeal. In general, the appeal process will take several months or more.

How Many Times Can I Appeal My Washington D.C. Workers’ Comp Case?

If the D.C. Court of Appeals denies your claim, then there are no other options to appeal. Their decision is final. However, if the Court of Appeals reverses a decision, then it will remand the case to an Administrative Law Judge for a new hearing.

Why Do I Need a Workers’ Comp Attorney?

Workers’ compensation appeals specifically in Washington D.C. can be very complicated, and having a workers’ comp lawyer help with this process can be very beneficial. They will help you meet any required deadlines and gather evidence to present the best case possible.

Insurance carriers, such as The Hartford or Travelers, will have their own attorney, medical experts, investigators, case managers, and adjusters that will all be working against you. Having an experienced workers’ compensation lawyer on your side will help even the playing field and make you much more prepared to go up against the insurance company team of workers comp specialists.

Did the Insurance Company Wrongly Deny Your Workers’ Comp Claim?

The experienced workers’ comp attorneys at Donahoe Kearney know how to handle insurance companies. We have extensive experience in D.C. workers’ compensation, and we use it to fight back and get hard-working employees the benefits they deserve. We have literally written the book on the D.C. Workers’ Compensation system — call us today at 202-393-3320 and we will send you a copy, absolutely free of charge (we even pay shipping) with no obligation. Do not take a chance on losing the benefits and medical treatment you need. Contact our team today for more information or to schedule a free consultation that’s 100% confidential.

by Frank R. Kearney, Attorney-at-Law

Experienced DC Workers’ Comp, Long Term Disability & Accident Lawyer,

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