The most common reasons for worker’s compensation “denied my claim” in Wisconsin are the injury or condition is not work related, in other words, it did not happen at work or because of job duties or the extent of the disability is disputed.
Whenever benefits are denied, the workers comp insurance carrier is required to advise the claimant of his or her right to a hearing with the DWD. Wis. Admin. Code § DWD 80.02(2)(g)2. In serious injury cases in which the injured workers hires an attorney, the attorney’s first step is to investigate and determine whether jurisdiction, liability, and extent of disability and the basis for the denial. The attorney then collects the relevant medical records, any IME report and possibly the worker’s employment file or the DWD file in Madison.
The next step for the attorney is to file with the DWD an application for hearing, which states the nature of the claim, ie. back injury, the matters in dispute and the benefits claimed. Because a hearing results in a final decision if the case is not successful, the best practice is usually to file for a hearing only when the entire claim is ready, for example, when the full extent of the loss of earning capacity is known. A premature hearing on causation and a small amount of medical expense or workers compensation benefits, does not lend for a favorable negotiated settlement and could prematurely end an otherwise meritorious case. It may not be necessary to file a treating doctor’s opinion on a 16B form with the application for hearing, but a hearing will not be held until the requisite doctor’s opinions are filed supporting the claimed benefits. Our office generally files doctor opinions with the application and supplements later with additional opinions as available from additional doctors.
The insurance carrier is required to file an answer to the application with the DWD and with the claimant or the claimant’s attorney. The purpose of the answer is to inform the applicant and the department exactly what issues are in dispute. General denial of all issues without explanation is not acceptable to the department.
The DWD will not schedule a hearing until the applicant files a Certificate of Readiness, which once again clarifies the issues in dispute and the benefits sought. Just before the hearing, additional medical records, bills and mileage claims are filed along with any supplemental medical or vocational opinions.
McCormick Law Office in Milwaukee, Wisconsin fights workers compensation denied my claim determinations by amassing trustworthy and legitimate medical opinions to overcome IME opinion based denials. Generally we file for hearing when the injured worker reaches the healing plateau and the full benefits are discernable.