Getting hurt on the job is tough, and a denied workers’ comp claim can make it even worse. But do not let that discourage you—a denial does not mean it is over. In South Dakota, you can appeal the decision, and knowing what to do next can help you fight for the benefits you deserve.
Common Reasons Workers’ Compensation Claims Get Denied
Before appealing, understand why your claim was denied. Insurance companies often look for reasons to reject claims. Here are common ones:
- Missed Deadlines: You have three business days to report your injury in South Dakota. Waiting too long can lead to denial.
- Lack of Medical Evidence: Insurers may dispute a work-related injury if your records do not clearly show it.
- Employer Disputes: Your boss or their insurer might argue that your injury didn’t happen at work or is not serious.
- Pre-Existing Conditions: They might blame your injury on a past condition instead of your job.
- Not Following Treatment: Skipping doctor visits or ignoring medical advice can hurt your case.
- Employment Status: Independent contractors and some workers may not qualify for benefits.
A denial is not final. Many workers win appeals by following the proper steps.
Steps to Appeal a Workers’ Compensation Denial
Here’s how to appeal the denial of your claim.
Review Your Denial Letter
Have a lawyer review your denial letter. They can explain why your claim was rejected and what steps you can take next. Understanding the reasons for denial will help you determine the best way to challenge the decision.
Gather More Evidence
If you are going to appeal, you will need solid proof that your injury is real and happened at work. Some key things to gather include:
- Medical Records: Doctor’s notes, test results, and other medical documents supporting your claim.
- Accident Reports: If you filed an incident report at work, get a copy.
- Witness Statements: Coworkers or others who saw what happened can provide written statements.
- Expert Opinions: Sometimes, a doctor or specialist might need to write a report explaining how your injury is job-related.
The stronger your evidence, the better your chances of overturning the denial and getting the benefits you deserve.
File a Petition for a Hearing
If your claim gets denied, your lawyer can request a formal hearing with the South Dakota Department of Labor and Regulation. They will handle the paperwork, file everything on time, and create a strong case for you. You have two years from your injury date or last benefits payment to do this, so don’t wait too long, or you could lose your chance to appeal.
Try Mediation First
Before going to a hearing, South Dakota recommends mediation. This means you and the insurance company will sit down with a neutral mediator who will try to help both sides reach an agreement. If mediation works, you won’t have to go through a formal hearing. If not, your case moves forward.
Prepare for Your Workers’ Comp Hearing
If mediation fails, the next step is a hearing with a judge—basically a mini-trial. Your lawyer will present your case, bring evidence, and call witnesses, and the insurance company will do the same.
To win, you need to:
- Have strong medical evidence proving your injury is work-related
- Be prepared to answer questions about your claim
- Bring any witnesses who can support your case
- Challenge any false claims made by the insurance company
Winning your case comes down to concrete evidence, preparation, and standing firm against any pushback from the insurance company.
Appeal to Circuit Court If Necessary
If the judge rules against you, you can take your case to South Dakota Circuit Court. This is a more intricate legal process; having an attorney is almost necessary at this stage.
Should You Hire a Lawyer for a Workers’ Comp Appeal?
You don’t technically need a lawyer to appeal a workers’ comp denial, but going up against an insurance company’s legal team alone isn’t easy. Their job is to pay out as little as possible, and without experienced legal help, you could be at a disadvantage. A good workers’ comp lawyer can make sure you meet deadlines, gather strong evidence, negotiate with the insurance company, and represent you at hearings. Many workers who hire a lawyer end up with much better results than those who try to handle their cases independently.
How Long Does a Workers’ Comp Appeal Take?
Appeals take time, so don’t expect a quick decision. The process can last anywhere from a few months to over a year, depending on your case. Mediation might take a few weeks or months, scheduling a hearing can take several months, and a judge’s decision could take even longer. If further appeals are needed, it could stretch past a year. If you’re struggling financially while waiting, looking into short-term disability or assistance programs might help.
What Happens If You Win Your Appeal?
If you win your appeal, you will finally get the benefits you should have gotten in the first place. This could include:
- Medical Coverage: Your workers’ comp should cover medical bills, therapy, and any future treatment related to your injury.
- Lost Wages: If you have been out of work, your benefit should include temporary total disability benefits, which cover a portion of your lost income.
- Disability Benefits: If your injury prevents you from returning to work at all, you could qualify for permanent total disability benefits.
A successful appeal means financial relief and the support you need to recover and move forward.
What If You Lose Your Appeal?
If your appeal gets denied, don’t give up just yet—you might still have options. It may be possible to appeal the Circuit Court’s decision. Your lawyer can advise you about that. You can also look into other benefits like Social Security Disability, use your long-term disability policy if you have one, or ask your lawyer if there’s anything else you can do. A denial doesn’t always mean it’s over, so keep exploring your options and fighting for the benefits you deserve.
Need Help with a Workers’ Compensation Appeal?
Getting denied for workers’ comp does not mean the end of the road. You still have a chance to fight for the benefits you need. Turbak Law Office, P.C.’s experienced workers’ compensation lawyers have helped many South Dakota workers take on demanding insurance companies and win their cases. If you need help, visit our contact page or call us at 605-886-8361 today.