A guide to common questions about controverted workers’ compensation claims
The word “controverted” can be a scary thing to hear for anyone who has filed a workers’ compensation claim. If you’ve been hurt at work, you should be focused on finding a way to get the compensation you deserve and pay your bills. Yet, recovering compensation for a workplace injury is not always a straightforward process.
What does it mean for a claim to be “controverted”?
Under Georgia’s workers’ compensation laws, your employer (and their insurance company) has the right to “controvert” the compensation claim you filed. A claim being marked “controverted” indicates that your employer or their insurance has decided to deny your claim in whole or in part.
Once a claim is controverted, the impact can be significant. A controverted claim typically means that your employer will refuse to pay any component of the claim. This means that not only will you not receive lost wages, but you also will be denied payment for medical care.
In the absence of alleged fraud, a controverted claim typically arises when an employer is alleging that your injury did not occur in the course of your employment. However, this is an oversimplification. There are numerous reasons why an employer or insurer might controvert a claim.
Some of the most common reasons include:
- They claim your injury did not stem from a job-related task.
- They claim that you had a non-disclosed pre-existing injury.
- They claim your injury was at work, but due to “horseplay” or other unrelated action.
- They claim no accident occurred and you fabricated the entire story.
- They claim proper notice was not given and the 30-day time limit for reporting the injury has expired.
Regardless of the reason cited, once a claim is controverted, you will be blocked from receiving the compensation and benefits you deserve. At this point, there is little you alone can do. Workers’ compensation laws are very nuanced and complicated, and attempting to remedy a situation by yourself is unlikely to be successful. Thus, it is imperative that you contact a qualified lawyer immediately once you are given notice that your claim is controverted.
As mentioned above, an employer will not necessarily controvert an entire claim. Often, they may simply controvert a portion of your claim. In these cases, they will typically admit that you were hurt in the course of your employment, but argue that you are not eligible for every available compensation benefit.
Generally, partially controverted claims will take 1 of 3 forms:
- They will argue that the doctor you saw did not specifically state that you were fully incapable of working, and thus you aren’t entitled to weekly wage compensation.
- They will argue that they should only be required to pay for a portion of your medical care, such as only paying for a leg injury but not the lower back injury.
- They will try to categorize your medical care as “unauthorized” (received without prior approval) and thus refuse to pay for it.
What should you do if your claim is controverted?
The first step in dealing with a controverted claim is to contact a qualified lawyer immediately. Typically, the next step is to request a hearing with the State Board of Workers’ Compensation Claims. Once a case is allowed a hearing, your lawyer will be able to introduce evidence of the legitimacy of your injury and your rights to compensation.
However, once a hearing has been requested, it is very common for the employer or insurance company to offer a settlement. Appearing in a hearing is an expensive and time-consuming process for a company. Thus, their willingness to offer you the compensation you deserve is much higher when they are faced with presenting a formal case before a judge.
These settlements can take 2 routes.
Sometimes, the employer will admit an error in their controverted claim and reverse the challenge, thereby granting you compensation. This is uncommon. More commonly, the insurance company will offer what is known as a “no liability stipulation.”
When this occurs, the insurance company is stating that, while they don’t admit any fault and continue to believe you were not injured, they will offer you a lump-sum package. Typically, such a package requires quitting your job and agreeing to not pursue the matter any further. Sometimes, this is a lucrative deal, while other times it requires further negotiation or consideration.
Remember that it likely wasn’t your employer’s decision
It is common for employees to feel anger towards their employers when a workers’ compensation claim is controverted. This is natural, and it’s understandable to feel betrayed if you’ve spent many years working for a company. However, it is important to remember that your employer typically does not have a hand in the decision to controvert a claim. Rather, once the claim is filed, their insurance company is the one who tries to find a method to reduce the cost of the claim.
This is an understandably frustrating process. However, many cases can be resolved in such a way that the injured party receives at least some of the compensation they deserve. The most important step is to always contact a law firm with experience handling Georgia worker’s compensation claims. At Gerber & Holder Law, we have the experience and skill needed to get you the money you deserve.