Most workers’ compensation claims in Arizona are approved upon their submittal. But what happens if your workers’ compensation benefits claim is among the minority of applications that the Industrial Commission oWhat are the Chances of Winning a Workers’ Compensation Appeal?
If your Arizona workers’ compensation claim has been denied, the good news is that an appeal is not a long shot.
Published estimates of how often initial workers’ compensation claims are denied vary — generally falling somewhere between 7% and 25% depending on the state and the source — and a meaningful share of denied claims are overturned once an injured worker takes the case to the Industrial Commission of Arizona (ICA).
Your chances of winning a workers’ compensation appeal depend on how quickly you act, the strength of the medical evidence supporting your claim, and the experience of the attorney representing you. Understanding your options after a denial is vital, and the sections below walk you through the appeal process and how to give yourself the best chance of winning.
To learn more about our workers’ compensation services and to speak with an experienced Arizona workers’ compensation appeal attorney, call Matt Fendon Law Group at (800) 229-3880. Or if you prefer, you can reach us online, and we will get back to you promptly.
How to Improve Your Chances of Winning a Denied Workers’ Compensation Appeal
To employers and workers’ compensation insurers, key considerations in deciding whether to contest an appeal of a denied workers’ compensation claim are the cost of defending the appeal and the real possibility that an Administrative Law Judge will overturn the denial when the injured worker comes prepared with strong evidence and experienced counsel.
It follows that your odds of winning your appeal of a workers’ compensation claim denial increase when you are well prepared to challenge a denial. Here are some important considerations when preparing your appeal.
- Act quickly. Remember, you have only a limited time to file your notices to the ICA and, if applicable, to the Arizona Court of Appeals. Do not risk losing your appeal by waiting too long to act.
- Follow all medical advice. Insurance companies often cite non-compliance with medical treatment as grounds for denying claims. To minimize this possibility, attend all medical appointments, follow any treatment plans exactly as prescribed, document any side effects or issues with your treatment, and maintain communication with your healthcare providers.
- Keep detailed records. Keep all copies of paperwork you receive from your employer, the workers’ compensation insurance company, and your doctor. Track your medical appointments and treatments, and record how your injury or illness affects your daily life activities. Save receipts for your related out-of-pocket expenses.
- Gather your medical evidence. The strength and clarity of your medical evidence is the single most important factor affecting your appeal’s success. Persuasive medical evidence includes clear diagnoses from qualified medical professionals, medical opinions connecting your injury to your work activities, detailed treatment records and documentation of limitations, and testimony from treating physicians or independent medical experts.
- Be Consistent in Your Statements. Be truthful and consistent when explaining how your injury or illness occurred, your symptoms and limitations, your prior medical history, and your work activities and restrictions.
How Can an Arizona Workers’ Compensation Lawyer Increase Your Appeal Chances?
Appealing a workers’ compensation claim denial requires careful preparation and a methodical approach that ensures you do not miss filing deadlines and prepare an organized, persuasive case to the ICA or to the Court of Appeals. An experienced Arizona workers’ compensation attorney can help you with all of these important considerations.
Specifically, your lawyer can do the following to make sure your appeal is as strong as possible:
- Expert case preparation
- Navigating rules and deadlines
- Advocacy at hearings
- Knowledge of the workers’ compensation system
Taken together, these factors can compel the workers’ compensation insurance carrier to take your claim appeal seriously, improve your chances of winning a workers’ compensation appeal, and, in some cases, can lead to a reconsideration of a claim denial.
What is the Appeal Process for Arizona Workers’ Compensation?
If your initial claim gets denied, then the Arizona workers’ compensation appeals process requires you to take the following steps.
Request a Hearing With the Industrial Commission of Arizona
Within 90 days from the date of the denial (the “Notice of Claim Status” that denied or ended benefits), you must file your request for a hearing with the Industrial Commission of Arizona (the ICA) to contest the denial. This begins the formal appeals process.
When the ICA receives your hearing request, it will assign your appeal to an Administrative Law Judge (ALJ) to handle your dispute.
After you file, there may be a pre-hearing process, which can take the form of a conference or an exchange of evidence. This is similar to discovery in a lawsuit, as it ensures that both sides share relevant information.
Appeal Hearing Before the Administrative Law Judge
The ICA will schedule a formal hearing for your appeal. This usually takes place a few weeks or months after your request.
The hearing is like a trial in some ways, but it is less formal. You and your workers’ compensation attorney and the insurance company will have the opportunity to present evidence and witness testimony. Both sides can also cross-examine each other’s witnesses.
Typically, the Initial Hearing is scheduled for your testimony and the testimony of non-medical witnesses (lay witnesses). If medical testimony is needed, then further hearings are scheduled for the doctors to testify. Your doctor testifies at a further hearing, and the defense doctor at a later further hearing.
After the hearings are held and all the evidence is in, the matter is deemed submitted. Then, the ALJ will issue a written decision after considering all the evidence. In Arizona, ALJ decisions are typically issued within 30 to 60 days of the case being submitted to the judge. However, the exact timing can vary depending on whether a post-hearing briefing is required. The Award will state whether you are to receive benefits or if the denial stands.
Post-Hearing Request for Review
If you disagree with the ALJ’s decision, you may file a request for review within 30 days of the mailing date of the decision. This is called a “Decision Upon Review.”
The ALJ will re-examine the evidence and any written arguments submitted by you and the insurer. No new hearing is usually held, but the ALJ may correct, modify, or rescind findings.
The ALJ will either affirm or change the original decision. This marks the end of the ICA process. The Decision Upon Review will become final unless you escalate the appeal to the Court of Appeals by filing a Special Action.
Appeal to the Arizona Court of Appeals
The end of the ICA appeal process is not necessarily the end of your options. If you still believe that you have a valid claim for workers’ compensation, then within 30 days after the ICA’s Decision Upon Review, you can file a petition for special action (industrial commission review) with the Arizona Court of Appeals.
This is a formal appeal that is heard by a panel of three judges. The court of appeals does not hold a new trial. Instead, it reviews the ICA record (the evidence and transcripts from your hearing) to decide if the ALJ made any legal errors or abused discretion.
The Court of Appeals will issue a decision upholding the ICA’s decision or, if errors are found, setting it aside and remanding it to the ICA for a hearing de novo. This decision is binding unless further appealed.
Possible Arizona Supreme Court Review
The last stage of the workers’ compensation claim denial appeal process may be a review by the Arizona Supreme Court. You have 30 days after the Court of Appeals issues its final judgment to petition the Supreme Court.
Review by the Arizona Supreme Court is not assured. The court chooses which cases to hear, focusing on those with broad legal importance. It declines to hear many petitions, so reaching this level is relatively rare in a workers’ compensation claim.
If the Supreme Court agrees to review your appeal, then it can affirm or overturn the lower court’s ruling. If it declines, then the Court of Appeals decision stands.
What Are Common Reasons Why Workers’ Compensation Claims Get Denied?
Your workers’ compensation insurance claim can be denied for several reasons. Here are some of the more common ones we have encountered.
Insufficient or Disputed Medical Evidence
Workers’ compensation claims relieve you of the need to prove that your employer was negligent, but you still need evidence to support your claim. This evidence includes your medical records, diagnosis of your work-related injury, treatment records, doctor’s notes, physical evidence from the scene of the accident, test reports, witness statements, and more.
If your claim filing lacks enough evidence to convince the workers’ compensation insurance company that your claim is real or that it was connected with your employment, this can lead to the insurer resisting your claim.
Also, your employer’s insurer can require you to undergo an independent medical examination (IME) with a doctor of its choosing. Sometimes these doctors, whom the insurance company is paying for, can disagree with your treating doctor about the existence or severity of your injury, illness, or medical condition or its connection to your employment.
Disputes Over Work-Related Causation
To receive claim approval for workers’ compensation benefits, you must show that your injury or medical condition is connected with your work. For example, injuries that develop slowly over time may have a cause other than an incident on the job or a pre-existing condition, which could be a potential alternative explanation.
If the workers’ compensation insurance carrier is unconvinced of this, chances are good that the insurer will refuse its approval of your claim.
Missed Deadlines or Procedural Mistakes
Workers’ compensation claims depend on you taking action in a timely way to preserve your claim. If you delay reporting your injury to your employer or file your claim too late, then this can give the insurer the opening it needs to deny your claim.
Even simple paperwork errors, like incomplete forms or inconsistent information, can lead to a technical denial of your claim.
Similarly, if your claim is denied, then failing to request a hearing within 90 days can mean losing your appeal rights.
Employment Status Issues
Arizona workers’ compensation only covers employees. If the insurer contends that you were not a regular employee (for example, you are an independent contractor, volunteer, or otherwise not covered by the employer’s policy), then it may deny your claim on that basis.
It is not uncommon for employers and their insurers to argue about your status as an employee when it comes to workers’ compensation claims.
What Arizona Workers’ Compensation Does and Doesn’t Cover
Arizona workers’ compensation covers medical care, temporary and permanent disability benefits, and permanent impairment — but it does not pay for pain and suffering. Workers’ compensation is an exclusive remedy, meaning you generally cannot sue your employer for those non-economic damages.
The exception is when someone other than your employer, not a co-worker, contributed to your injury; in that situation, a separate third-party personal injury claim may allow you to recover for pain and suffering on top of your workers’ compensation benefits.
If you think a third party may have played a role in your injury, raise it with your attorney early.
Do You Need Help Appealing a Workers’ Compensation Claim Denial?
Having effective legal representation during the appeal process increases the likelihood that the insurance company will reconsider its denial of the claim before a court orders it to do so. This is where working with a Matt Fendon Law Group attorney can be valuable to you.
An experienced workers’ compensation lawyer can help you gather all the available evidence you need to support your side of the story, help you assess the true value of your claim, and deal with the insurance company and its attorneys on your behalf.
The Arizona workers’ compensation appeals process can be difficult to navigate on your own, especially when it comes to gathering sufficient proof to establish a work connection to your injury, illness, or medical condition.
At Matt Fendon Law Group, our workers’ compensation attorneys handle ICA denials of initial workers’ compensation claims. Workers can and do succeed on appeal — particularly when they act within the deadlines and have experienced legal representation guiding the case from the start.
Call us at (800) 229-3880 to speak with an experienced workers’ compensation attorney about your claim denial. You can also reach us via our online contact form to schedule a free initial consultation.
