August 10, 2015

Should I Appeal a Denial of a Oregon Workers' Compensation Claim?

Should I Appeal a Denial of my Oregon Workers' Compensation Claim?

The short answer is YES.

The long answer...

So, you filed a workers' compensation claim in Oregon, and have now received a denial letter from the insurance company.  The letter will say something along the lines of:

                Dear Ms. Doe:

                We are unable to accept your claim for an injury to your low back because evidence does                     not show it was related to your employment.  This denial is based in part on an Independent                 Medical Examination (IME).  Your attending physician has not commented on the IME.


Why Was My Workers' Comp Claim Denied?

There are several reasons a claim is denied.

First, the insurance company is hoping you will not appeal the denial.  This reason has nothing to do with whether you have a good claim or not.  The insurance company denies lots of claims and not all of them are appealed.  So, it is good math for the insurance company to issue denials of claims that are totally valid as some of them will never be appealed.

Second, the employer told the insurance company you made up the injury.  Often employers are annoyed or even angry when a workers' comp claim is filed. They react by telling the insurance company to deny the claim.  However, this does not mean that it is true, just that the insurance company has bad facts.  The truth will come out when you appeal the denial.

Third, the IME doctor says your injury is not work-related.  Often, while investigating a claim, you will be sent to see an IME doctor who works for the insurance company.  That doctor is basically hired to give the insurance company a reason to issue a denial.  Most of the time the IME doctor will offer an opinion that your injury is not work-related.  The insurer will then issue a denial.  Again, this does not mean you do not have a perfectly valid workers' comp claim.

Fourth, the medical evidence is iffy.  Sometimes it is actually a close call as to whether your condition is work-related.  This happens when you had a prior injury to the same body part or have developed a condition that might be hereditary (such as hearing loss).  Again, this does not mean that you cannot win your claim, just that the insurance company wants to fight it.


Of all the denied claims that are appealed, most are settled for lump sum dollar amounts before a hearing ever takes place (I would estimate about 80 percent of appealed denials).  The rest go to a hearing before a workers' comp judge and about half of those are won by the claimant (injured worker).  Taking these statistics into account, it is almost always very worth it to appeal a denial of your workers' comp claim.

Will Appealing a Denial Cost You Anything?

No.  You will need an attorney, but workers' comp attorneys in Oregon must work on contingency.  This means the attorney is not paid unless you are.  In most cases, the fee does not even come out of your benefits, it is paid directly by the insurance company in addition to your workers' compensation benefits.

How Do I Appeal My Workers' Compensation Denial?

Get an attorney within the 60 day deadline.  You will need an attorney to help you file the appeal and to represent you in battling the insurance company for your benefits.

As always, if you have more questions or would like assistance with a denied claim, call my office for a free attorney consultation.   (503) 975-5535

1 comment:

  1. I never really understood the idea of appealing a ruling when I was younger. I always thought that it was best to just live with whatever we got. Then I realized that oftentimes there are biases in the rulings making an appeal the best course of action. Hopefully more people will realize that and do what they can to help themselves as much as they can with these things.