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What happens when a claim is denied?

By May 19, 2021No Comments

When liability for payment of compensation is denied, the Commission, claimant, his or her attorney (if any), and all known providers of health care shall be promptly notified of the reason for such denial.

The denial Form 61 shall not be worded in general terms, but must detail the exact reason for the denial of liability.

If a claim is denied by the insurance company or self-insurer, the employee may request a hearing before the Industrial Commission by submitting a Form 33, Request for Hearing. Medical providers may bill the employee only after it has finally been determined that it is not a compensable workers’ compensation claim.

The case will then be ordered into a Mediation before hearing is held to see if the case or issue can be settled. If settlement can not be reached then a full hearing or trial is held to make decisions for the parties.

If any part of the case is denied the parties need legal representation to help them through this process. Evidence issues and hearing rules make this process very difficult without a lawyer to help navigate the case.