Denied Benefits and Appeals Attorney in Orlando, Florida

A denied workers' compensation claim or a reduction in benefits can leave you facing financial uncertainty, making it essential to have an experienced attorney on your side to protect your rights and fight for your compensation.

Our skilled workers' compensation attorney at Reese Legal can help you work through the process of challenging a denial, handling appeals, and fighting for your benefits. Attorney Michael Reese has a deep understanding of workers' compensation laws and experience in denied claims. We're committed to advocating on your behalf, so you can rest assured your claim is in the right hands.

What Workers' Compensation Benefits Are Offered in Florida?

Florida’s workers' compensation system is designed to provide no-fault benefits to employees who are injured or become ill as a result of their job. Some of the most commonly offered benefits include:

• Medical treatment: Coverage for necessary medical treatment related to the injury.

• Temporary disability benefits: Compensation for lost wages if an employee is temporarily unable to work due to their injury.

• Permanent disability benefits: Compensation if the worker suffers lasting impairments that affect their ability to work.

• Vocational rehabilitation: Assistance for workers who cannot return to their previous job, including job retraining or job placement services.

• Death benefits: For the family members of a worker who dies as a result of a work-related injury or illness.

Despite the availability of these benefits, workers may find themselves in situations where their claims are denied. The reasons for such denials are varied, and understanding them is crucial for workers who are seeking to work through the system.

Common Reasons for Denial of Workers' Compensation Claims

In Florida, several factors may lead to the denial of a workers' compensation claim. These factors can range from administrative issues to more complicated disputes regarding the validity of the injury or illness. Below are some common reasons for a claim denial:

1. Failure to Report the Injury Promptly

Florida law requires that an injured worker report the injury to their employer as soon as possible, but no later than 30 days after the accident or the onset of symptoms related to a work-related illness. If a worker fails to report the injury in a timely manner, the insurance company may deny the claim, arguing that the injury isn’t related to the work environment or that it occurred too long ago to be verified.

2. Lack of Medical Evidence

For a claim to be successful, the injured worker must provide sufficient medical documentation proving that the injury or illness is work-related. 

If the worker fails to submit adequate medical records, or if the doctor’s opinion doesn't link the condition to the workplace, the insurance company may deny the claim. Insurance companies may also dispute the nature of the injury, arguing that it's pre-existing or unrelated to the workplace.

3. Pre-Existing Conditions

If a worker has a pre-existing condition that's aggravated by a workplace injury, the insurance company may deny the claim, arguing that the injury was not caused by the job, but rather the worker's prior condition. 

This is a common issue in cases of repetitive stress injuries, such as carpal tunnel syndrome or back pain, where it may be difficult to separate the effects of the pre-existing condition from the workplace injury.

4. Failure to Seek Medical Treatment

Florida workers' compensation law stipulates that an injured worker must seek treatment from an approved medical provider. If the worker fails to visit a doctor or receives treatment from an unauthorized healthcare provider, the claim could be denied. 

Additionally, if the worker refuses medical treatment or fails to follow prescribed treatments, the insurer may argue that the worker isn’t taking reasonable steps to recover.

5. Employer Denial or Disputes

Some employers may dispute the circumstances of the injury, denying that the incident occurred while the worker was on the job. In cases of workplace accidents, if the employer claims that the injury happened outside of work or that the employee was not performing job-related duties at the time, the insurance company may deny the claim. 

This can be particularly common in cases where the injury is alleged to have occurred during a break or while the worker was engaging in non-work-related activities.

6. Failure to Meet the Legal Definition of “Injury” or “Illness”

Not all injuries or illnesses are covered under Florida's workers' compensation law. For example, if the injury was self-inflicted or if the worker was under the influence of drugs or alcohol at the time of the accident, the claim may be denied. 

Similarly, some mental health conditions, such as stress or anxiety, may not qualify for workers' compensation unless they meet specific criteria for work-related mental injuries.

Steps to Take When Workers’ Compensation Benefits Are Denied

If a worker's claim for workers' compensation benefits is denied in Florida, they have the right to appeal the decision. The appeals process is designed to help make sure that workers receive the benefits to which they're entitled under the law. Below are the steps involved in appealing a workers’ compensation claim denial in Florida.

1. Request a Formal Denial From the Insurance Company

When a claim is denied, the first step is to obtain a formal denial letter from the insurance company. This letter will outline the reasons for the denial and provide details about how the claim was evaluated. It's important to review this letter carefully and make sure that all of the reasons for the denial are clearly understood.

2. File a Petition for Benefits

If the worker disagrees with the denial, they can file a Petition for Benefits with the Florida Division of Administrative Hearings (DOAH). The petition must be filed within two years from the date of the accident or the date of the last authorized payment of compensation (whichever is later). 

The petition outlines the benefits being requested and the reasons the worker believes the denial was incorrect.

Once the petition is filed, the DOAH will schedule a mediation or hearing. This is an opportunity for the worker and the insurance company to present evidence and attempt to resolve the dispute.

3. Mediation

Mediation is a voluntary and non-binding process designed to encourage both parties to reach a settlement. A mediator, often a retired judge or experienced attorney, will facilitate discussions between the injured worker and the insurance company. 

If both parties can agree on a settlement, the dispute may be resolved without the need for a formal hearing.

4. Hearing Before a Judge of Compensation Claims (JCC)

If mediation does not result in a resolution, the case will go to a hearing before a Judge of Compensation Claims (JCC). At this hearing, both the injured worker and the insurance company will present evidence and make arguments about why the claim should or shouldn’t be approved. 

The worker can present medical evidence, witness testimony, and expert opinions, while the insurance company may provide their own evidence to support the denial.

The JCC will then issue a ruling, which can take several weeks to arrive. If the worker is dissatisfied with the outcome, they may have the option to appeal the decision to the Florida First District Court of Appeal.

5. Appeal to the Florida First District Court of Appeal

If the worker’s claim is still denied after the hearing before the JCC, the worker can appeal the decision to the Florida First District Court of Appeal. The court will review the legal aspects of the case, and it can either uphold the JCC’s decision or send the case back for further consideration.

While the appeals process can be time-consuming and complicated, with the right support and preparation, workers can often succeed in overturning a denial and receiving the necessary benefits for their recovery. Working with an experienced lawyer, like Attorney Michael Reese, can also be helpful.