You don’t have to prove negligence or show that your employer did anything wrong to cause your injury. Even if your injury was your own fault, you can still collect benefits.
You have 90 days to report your injury to your employer and two years to file a workers’ compensation claim, but you should do both as soon as possible. Your employer is not legally permitted to fire you or retaliate against you in any other way for filing a workers’ comp claim.
What If Your Workers' Compensation Claim Is Denied?
If your workers’ compensation claim is denied by your employer’s insurance company, this is not necessarily the final word on your case. You can try to settle the dispute by meeting informally with your employer and/or the insurance company. If an informal meeting does not solve the problem, however, you may file a formal appeal with the South Carolina Workers’ Compensation Commission (SCWCC).
The SCWCC administers workers’ compensation throughout the state and oversees employees’ claims. When an employee contests a claim denial or disagrees with a part of an award, the Commission holds a hearing and issues a decision on the appeal. You are not required to have legal representation for this process, but your chances of getting a favorable decision are better with the help of a workers’ comp attorney than without one.
Why South Carolina Workers’ Compensation Claims Are Denied
Insurance company adjusters are trained to save the company money by denying or devaluing as many claims as possible. If you’ve filed a workers’ comp claim, your employer’s insurance company will try to find any way possible to dispute the claim and devalue your injuries or illness.
More than 10% of SC workers’ compensation claims are denied. Common reasons include:
- The application provided incomplete information.
- There was a discrepancy between the accident report and documented injuries.
- The applicant missed the notification and/or filing deadlines.
- Medical treatment was not sought.
- The medical provider was not on the certified list of providers.
- The injury did not happen at work.
- The injury is not severe enough to warrant benefits.
- The employer disputes the claim, stating that the claimant had a pre-existing medical condition, was a contractor, or was impaired by drugs or alcohol when the injury occurred.
If your claim is denied, you should receive a letter stating the exact reason for the denial and giving information regarding a possible appeal. You generally have two years from the date of the injury to file that appeal, but filing sooner is always better. If you wait, the insurance company might try to cite your delay as evidence that your injury/illness was not as serious as you say it was.
Steps in the Workers’ Comp Appeals Process
There are several levels in the process of appealing your workers’ compensation claim denial.
When you receive your initial denial, your first step should be to meet with your employer and/or the employer’s insurance company to see if the denial is due to a minor issue like a typo or other clerical error that can be corrected without SCWCC intervention.
SCWCC hearing request.
If an informal meeting does not resolve the problem, you may submit a hearing request and a $25 fee to the SCWCC. Your hearing will be held before one commissioner in the county where your injury occurred. You might be required to see an SCWCC-recommended doctor, who will also testify at your hearing. Then, the commissioner will issue an order stating the SCWCC’s decision.
If you disagree with the order, you have 14 days to appeal by submitting a Request for Commission Review, along with a $150 fee. At this second level of appeal, three commissioners will hear your case and make their decision, which is called an “award.” You will be notified of the award with an explanation of the Commission’s rulings on the facts of your case.
SC Court of Appeals.
If you disagree with the award that results from your Commission review, you have 30 days to file a lawsuit in the South Carolina Court of Appeals. When you file the suit, you must explain your reasoning, citing mistakes you feel the SCWCC has made in interpreting the facts of your case and/or applying the law. While this appeal is pending, your employer is required to pay you weekly cash benefits, and the insurance company must cover your ongoing medical care.
SC Supreme Court.
If you are not successful at the Court of Appeals level, you still have one more option. You may take your claim to the South Carolina Supreme Court, which will evaluate your case and decide whether to hear your final appeal. The Supreme Court chooses which cases it will hear and has no obligation to hear each one.
You will need the services of an experienced attorney who can help you navigate the complex workers’ compensation appeals process. There are strict time limits and rules of procedure to follow at every stage. Your lawyer will make sure that you don’t miss a deadline, violate a rule, or do anything else harmful to your case. Because your employer and the insurance company will have a team of lawyers to argue against you, you want a lawyer in your corner to present your evidence convincingly and fight for the compensation you deserve.
Has Your Workers’ Compensation Claim Been Denied?
Learn about your appeals options by requesting a free copy of our book, The Truth About Your South Carolina Workers’ Compensation Claim, and consulting our experienced South Carolina workers’ comp attorneys.
Please contact us online, start a chat, or call our Myrtle Beach, North Myrtle Beach, or Conway office directly at 843.488.2359 to schedule a free consultation. We serve clients throughout Horry County and surrounding areas, so we’re sure to have an office near you. We accept cases on a contingency fee basis, so you pay no attorney fees until we win your case.