Was your work injury claim denied or rejected? Understand your right to appeal in Georgia.
In a workers’ compensation case, there are 2 main ways in which a case can be denied. Therefore, there are 2 ways in which a case can be appealed. In this article, we will review how a case can be denied, what can be done to get the denial overturned, and how to appeal a denial.
Types of workers’ compensation claim denial
The 2 main types of denial are:
1. Denial of the claim as a whole (which means the insurance company denies that there was an injury in the scope and course of the injured workers’ claim)
2. Denial of a certain aspect of a workers’ compensation claim (be it medical treatment with a specific doctor, denial of a certain body part that the injured worker asserts they hurt on the job, etc.)
Both of these denials prevent the injured worker from receiving a benefit that they may be entitled to under the Georgia workers’ compensation statute.
Types of workers’ compensation appeals
Appeals of the denial of services in a workers’ compensation case can take two forms.
1. Administrative law judge. The first appeal of a denial of benefits is to go to a hearing before an administrative law judge.
2. State Board and courts. The second type is to appeal a decision by an administrative law judge to the full Board of Workers’ Compensation, and then subsequently to a superior court judge, the Court of Appeals and then possibly the Georgia Supreme Court.
Remember that a workers’ compensation claim resides in state law, and therefore there is no federal jurisdiction, so appeals can’t go to federal court or the U.S. Supreme Court.
How to appeal a denied workers’ comp claim in Georgia
If a claim is denied at the outset, it means that the insurance company either doesn’t believe that the individual is injured, or that the injury was caused by the workers’ activities on the job. In such a case, indemnity benefits aren’t provided to the injured worker, even if medical benefits are given. There is a strange anomaly in Georgia workers’ compensation law that allows an insurance company to pay for medical treatment without paying for indemnity benefits.
For example, an individual can be hurt on the job and the insurance company can be providing them medical treatment, which may either disable them or place them on light-duty restrictions. The insurance company can continue to pay for medical treatment without paying indemnity benefits or accommodating restrictions. This, along with the aforementioned outright refusing to pay benefits of any kind, is considered a denial of a claim.
A denial can be appealed by filing a hearing request and preparing to go to trial. The request for a hearing must be filed in a timely fashion and before the statute of limitations expires.
Prior to a hearing going forward, discovery typically takes place between the parties. This means that interrogatories and requests for production of documents are served on both the insurance company and the injured worker. Medical records are obtained and depositions are held.
Once a hearing is requested, the Georgia State Board of Workers’ Compensation sends notice to all parties involved. This notice informs them of the date, time, and location of the hearing. Furthermore, the hearing notice also includes the name of the administrative law judge who will be presiding over the case. This judge hears all motions, discovery disputes and other evidentiary-related issues prior to the hearing, and also is the judge at the hearing as well.
O.C.G.A. 34-9-102 states that a workers’ compensation hearing should be held as quickly as practicable, but not less than 30 days—nor more than 90 days—after the request for the hearing.
What to expect at the workers’ compensation hearing
A hearing in a workers’ compensation claim is similar to a civil litigation hearing, except for 2 main important facts.
- First, there is no right to a jury trial in a workers’ compensation hearing. No matter how much an injured worker may desire a jury, there is no jury in a workers’ compensation case.
- Second, the administrative law judge cannot award a settlement to either side. The administrative law judge is merely the trier of fact (as established by O.C.G.A. 34-9-100), not a dispenser of monetary awards and settlements. The only benefits that an administrative law can award are indemnity benefits, medical treatment and incidental expenses such as mileage reimbursement, permanent partial disability benefits, penalties and assessed attorney’s fees.
That being said, the administrative law judge can rule on the compensability of a claim. They can determine that the injured worker was hurt on the job and therefore benefits should commence and potentially be retroactive.
O.C.G.A. 34-9-102(f) states:
That within thirty (30) days following the completion of evidence, unless the time has been extended by the board, an administrative law judge shall determine the questions and issues and file the decision with the record of the hearing…the decision of the administrative law judge shall be made in the form of a compensation award, appropriately titled to show its purpose and containing a concise report of the case, with findings of fact and conclusions of law and any other necessary explanation of the action taken… The compensation award shall be final 20 days after issuance of notice of the award unless an appeal is filed in accordance with Code Section 34-9-103
This ultimately means that the administrative law judge has to make a ruling after a hearing, and either party has 20 days to appeal the ruling. The appeal of the administrative law judge is heard by the appellate division of the State Board of Workers’ Compensation. After the initial party files their appeal, the other party has 30 days to file a cross appeal.
Appealing an administrative law judge’s ruling
The appeal to the Appellate Division is by default based upon brief only, unless a special request is made for oral argument. If an oral argument is requested by either party, an electronic notice sent via email is sent to the parties notifying them of the date of the oral argument.
The Appellate Division can remand the case back to an administrative law judge, or overturn, amend or affirm the award previously issued. Once an award from the Appellate Division has been handed down, O.C.G.A. 34-9-105 lays out the procedure for appealing that award to Superior Court.
Appealing the Appellate court’s decision
In order to take a workers’ compensation ruling to Superior Court, the Appellate Division’s award must be appealed within 20 days. The appeal must be filed in the county where the injury occurred—or if the injury took place out of state, in the county where the original hearing took place.
After the appeal is filed, the State Board of Workers’ Compensation has 30 days to transmit a certified copy of the file to the Superior Court. The hearing must then be held within 60 days of the date of docketing in the Superior Court, otherwise the order of the Appellate Division shall be deemed affirmed.
Additionally, the Superior Court has 20 days to issue an award if the hearing was held within 60 days of the docketing or the Appellate Division’s award is deemed affirmed as well.
There are only 5 reasons why the Superior Court will overturn a ruling from the Appellate Division of the State Board of Workers’ Compensation:
- The members acted without or in excess of their powers.
- The decision was procured by fraud.
- The facts found by the members do not support the decision.
- There is not sufficient competent evidence in the record to warrant the members making the decision.
- The decision is contrary to law.
The Superior Court cannot hear from new witnesses or award a jury trial. They are bound by the facts that have already been put in evidence.
Appealing a Superior Court ruling
If either party wants to appeal the Superior Court’s decision, they can appeal to the Georgia Court of Appeals and subsequently the Supreme Court of Georgia.
If you have any questions about appealing your workers’ compensation case, don’t hesitate to contact the experienced Athens work injury lawyers at Gerber & Holder Attorneys At Law.