What Happens If The Insurance Company Denies My Claim?

If the Workers’ Compensation Carrier has controverted or denied your case, a process starts to adjudicate the issue(s). The Carrier is obligated to file a Notice of Controversy within 25 days of the Notice of Indexing.

Typically, the Workers’ Compensation Board will schedule a Pre-Hearing Conference shortly after receiving the Notice of Controversy. Thereafter, both parties are required to file the documents necessary to prosecute or defend the case. The Board requires certain forms be filed, including a PH-16.2, “Pre-Hearing Conference Statement.”

That is why at MCV Law we recommend obtaining your medical evidence before completing the C-3. Otherwise, a claim may be denied or delayed for lack of medical evidence.

The Claimant’s PH-16.2 sets forth the facts and circumstances of the claim, names witnesses, and sets forth the legal theory upon which the case is based. The Carrier will file an opposing PH-16.2 laying out the reasons for denial of the claim.

Pre-Hearing Conference

At the Pre-Hearing Conference, the Court must determine whether the facts support a case and there is enough medical evidence to allow the case to move forward. This is called a finding of “prima facie medical evidence.”

The judge will then direct the following:

• Testimony of relevant witnesses,
• Medical testimony of the doctors, which is often taken by deposition,
• Memoranda of Law from both parties, and/or
• Continue the case for a decision.

If you have a controverted case, it’s important that you seek help, as the process is complicated and you can be tripped up by procedural requirements. It’s important to understand the requirements and have the relevant evidence. Unlike most civil cases, the Workers’ Compensation adjudication system does not have a formal Discovery process. However, Workers’ Compensation attorneys do have subpoena power to obtain certain documents and records.

The Judge

The judge sits as the adjudicator of the case and will hear the testimony. Sometimes, testimony is taken by telephone if the parties reside outside of the area. Medical testimony is often taken by out-of-Court deposition to allow an expedited hearing without having to bring the doctors into Court.

Independent Medical Exam

Especially in a controverted case, the Insurance Carrier is likely to have you examined by an Independent Medical Examiner (“IME”). The Workers’ Compensation Law has requirements for IME’s.

One of the most important pieces of the IME, often overlooked by injured workers, is the opportunity to make sure that the IME doctor has a complete history of how the injury occurred and the consequences of the injury. This should be consistent with the initial history that you gave your treating physician. If circumstances have changed, you should explain why. You are entitled to record the exam and bring people with you if you give notice.

Decision

Once the testimony has been taken and depositions have been completed, the Workers’ Compensation Board either schedules a hearing for the judge to hear arguments or the judge directs that the parties submit a written argument, often referred to as “Memorandum of Law.” Within a reasonable period of time, the judge will issue a decision establishing or denying the claim. If the decision is made after oral arguments, it is referred to as a “Bench Decision.” If after Memoranda of Law, it is referred to as a “Reserved Decision.”

Appeal

Each party has 30 days from the date of the decision to file an appeal. The initial appeal is filed with the Workers’ Compensation Board and is heard by a panel of three Commissioners. There is no set time for the Commissioners to issue a decision. Sometimes, the wait is very long.

A decision from the Commissioners, called a “Board Order”, may be appealed to the Full Board and/or to the Appellate Division of the Third Department of the New York State Supreme Court in Albany, N.Y.

Appeals from the Appellate Division are made to the Court of Appeals, the highest Court in New York.