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What Happens if Your Worker’s Compensation Claim is Denied in Greenville, SC?

If you’re hurt on the job in Greenville or anywhere in South Carolina, you may be entitled to worker’s compensation benefits, regardless of fault for the injury. Worker’s compensation can pay for the full cost of reasonable and necessary medical care arising from your work injury. It can also provide partial replacement of lost wages if you cannot work due to the injury, and certain other benefits if you have a permanent, disabling condition.

In theory, getting benefits should be simple. However, worker’s compensation insurance companies frequently dispute elements of claims or even deny claims altogether. If you’re in this situation, you want to understand the appeals process – and how a worker’s compensation attorney can guide you through it.

Why Worker’s Comp Claims Are Denied or Disputed in South Carolina

Worker’s compensation is a no-fault system, so “the accident was your fault” is generally not a reason to deny your claim. However, there are specific legal reasons why an insurance company can deny a worker’s compensation claim, including:

  • You were not on the job when the injury happened, or your injury did not happen because of your employment.
  • The injury was pre-existing and not caused by your employment.
  • You were an independent contractor rather than an employee at the time of the injury.
  • You intentionally injured yourself.
  • You were injured in a fight that you started.
  • You were intoxicated at work, and the intoxication was the cause of your injury.
  • You failed to report the injury in a timely manner (generally within 90 days).

In addition to outright denied claims, there are many aspects of a claim that the insurance company can potentially dispute. Some examples of disputes include:

  • How your average weekly wage (AWW) is calculated, which can drastically impact the amount of your possible temporary and permanent disability benefits.
  • Whether a particular medical procedure or medication is reasonable and necessary.
  • Whether you are able to return to work, with or without restrictions.
  • The impairment rating (percentage of disability) of a part of the body that is permanently injured.

If you disagree with the denial of your claim or dispute another aspect of your claim, then you may have options through the appeals process.

The Single-Commissioner Hearing to Resolve Disputes

The South Carolina Workers’ Compensation Commission (SWCC) is a seven-member commission that oversees the worker’s compensation system and conducts hearings to resolve disputes. The SWCC is based in Columbia but has hearing locations throughout the state. For example, Greenville County and neighboring Pickens County are in Hearing District 1, where hearings are held in Greenville.

Requesting a Hearing

The first step to trying to resolve any issues with your claim is to request a single-commissioner hearing. For instance, you can request a hearing if your claim was denied or if you believe you did not receive all the benefits you are due.

To request a hearing, you must fill out Form 50, Employee’s Request for Hearing. In addition to your and your employer’s contact information, this form requires you to provide information on the date and location of the accident, the type of injury, when you notified your employer of the injury, and medical information. Your attorney can fill out this form on your behalf.

The Pre-Hearing Conference

Usually, there will be a pre-hearing conference between the commissioner and the attorneys for both sides. This is an informal discussion of the issues to give the commissioner a preview of the evidence that will be used in the case. Sometimes, it’s possible to reach a settlement after the pre-hearing conference. If not, then the case can proceed to the hearing.

The Single-Commissioner Hearing

The hearing itself includes position statements (essentially opening statements), evidence such as documents, and any witness testimony and cross-examination. This may sound similar to a trial, but it’s more informal: there is no jury, just the commissioner, the parties, their attorneys, and occasionally some additional witnesses.

The commissioner generally does not reach a decision right away. Rather, the commissioner may not make a decision until weeks or sometimes even months later. Once a decision is made, the commissioner will send instructions regarding their findings and will ask the “winning” party to draft a Proposed Decision and Order.

Appealing the Commissioner’s Decision

If you disagree with the commissioner’s decision, there are three levels of appeals you can pursue:

Appeals to the SCWCC

The first level of appeal is to ask the rest of the SCWCC to review the single commissioner’s decision. Usually, these reviews are conducted by a three-member panel (which will not include the single commissioner who made the original decision). For particularly unusual issues, a further review may be conducted by a six-member panel – that is, the whole Commission, except for the single commissioner who made the original decision.

You can request a review by the Commission by completing Form 30, Request for Commission Review. You must file this form with the SCWCC within 14 days of receiving the single commissioner’s decision. Your attorney can also help you with this step.

One important thing to consider when appealing a single commissioner’s Decision and Order is the scope of review of the appeal panel is not limited. The Panel can consider all evidence and reach its own findings of fact and conclusions of law. However, after this level of appeal, only errors in the way the law(s) has been applied can be appealed.

Appeals to State Court

If you disagree with the decision made by the Commission, your attorney can appeal to the South Carolina Court of Appeals. You generally have 30 days from the Commission’s decision to file an appeal. Your attorney can further appeal the Court of Appeals’ decision to the South Carolina Supreme Court, which is the highest court. 

While there is no guarantee the Court of Appeals or the Supreme Court will grant your request for an appeal, the courts will generally intervene when there is a significant error or improper conclusion of law on the part of the SCWCC. An experienced South Carolina worker’s compensation attorney can review your situation and advise you on how to proceed.

Contact a Worker’s Compensation Attorney Today

If your worker’s compensation claim is disputed or you think it may be disputed, it’s in your interest to talk to an attorney about your options. Experienced South Carolina worker’s compensation lawyers understand the hearing and appeals process.

When considering whether to hire an attorney or not, it’s important to remember that the appeals process is complicated and time-consuming. Hiring an attorney before your initial hearing with a single commissioner is the recommended course of action.  It is much more difficult to move forward with your claim after you have already attended a hearing and received an undesirable Decision and Order.

Your lawyer can:

  • prepare you for each step in the process
  • represent you in negotiations, hearings, and any appeals
  • ensure you meet critical deadlines
  • try to get you the best result possible

There is no cost and no obligation to get a free case evaluation from a work injury attorney. If you were hurt on the job in Greenville or anywhere in South Carolina, talk to an attorney in your area today.

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