Denied Workers’ Comp Claim Lawyer in St. Louis

A judge denied the claim. The Commission reversed it.

A UPS delivery driver with a 35 year career injured his left knee at work. On its own it looked like a simple knee case, and the Administrative Law Judge denied benefits. The argument we took to appeal was that the knee could not be looked at on its own: he already carried a prior knee condition with surgery, a documented disc herniation and an earlier work-related ankle injury, and he had kept working through each of them. Together they made him unemployable.

The Labor and Industrial Relations Commission reversed, found the pre-existing disabilities were hindrances to employment, and held the Missouri Second Injury Fund responsible for permanent total disability. He received over $600,000 in back pay and $807.48 a week for life.

The employer said he was faking.

A police officer developed severe psychological injury after a suicide by cop incident. He was 36. The employer and the insurer took the position that he was malingering, which is the standard defense when the injury does not appear on imaging.

We tried the case in the Missouri Workers’ Compensation Court in Springfield and proved the injuries. He was awarded lifetime workers’ compensation benefits. Psychological claims are denied more often than physical ones, and they are won the same way, by documenting the condition properly rather than arguing about it.

The employer said she was not at work yet.

An HR manager slipped on unseen black ice in her employer’s parking lot one winter morning, fell backwards onto the back of her head and suffered a concussion and a significant neck injury. She never returned to work. The employer denied the workers’ compensation claim, arguing she was not within the course and scope of her employment while walking into the building.

The claim settled for $450,000 on the morning of trial. Because a third party was also responsible for the condition of the lot, we pursued the snow removal contractor and the property manager alongside it. The head injury side of this case is covered in more detail on our brain injury page.

Prior results do not guarantee a similar outcome. Every case is different and is judged on its own facts. The same applies to the client accounts on this page, including any reference to an improved offer.

First Things to Do After a Workers’ Comp Denial

1. Keep treating. A gap in treatment hurts your health and your case at the same time. If you have health insurance, use it while the dispute is pending, and keep every bill and explanation of benefits.
2. Write down your filing deadline. Missouri’s time limits are set out below. Whatever your date turns out to be, it is the most important date in your case. Do not drift toward it.
3. Gather the file. The denial letter, every medical record, your written injury report and proof you sent it, witness names, pay records, every letter and email from the insurer, and your own notes.
4. Get quieter, not louder. A pending dispute means the insurer is paying more attention, not less. Stay off social media, do not talk about the case with co-workers, and do not guess in any recorded statement. “I don’t know” is a complete answer. In serious claims, insurers also use surveillance, and what the camera doesn’t show explains why one clip is not the whole story.
5. Have the denial read by someone who knows what it rests on. By the time a letter goes out, the insurer, its adjusters and its reviewing doctors have committed to a position. It is worth knowing where you stand before you answer it.

What Happens After a Denial in Missouri

1. The Claim for Compensation is filed with the Division of Workers’ Compensation. This is what moves the dispute out of the insurer’s hands, and the employer and insurer have to file an answer to it.
2. Mediation and pre-hearing conferences. The Division holds settings before an Administrative Law Judge to narrow the issues and look for a resolution short of trial. A good number of denied claims resolve here. Insurers that meet organized medical evidence and a represented worker have a way of rediscovering their flexibility.
3. The medical evidence is built. Treating physicians, records, depositions and, where necessary, an independent evaluation of our own to answer the insurer’s.
4. A hearing is requested before an Administrative Law Judge. Where treatment or temporary disability payments have been stopped, a hardship hearing brings that dispute forward rather than waiting for the case to conclude. When the case is ready, a final hearing decides compensability and benefits.
5. The award can be appealed. An Application for Review goes to the Labor and Industrial Relations Commission within twenty days of the award, and from the Commission to the Missouri Court of Appeals. The UPS case above was won at this stage.

Missouri generally allows two years from the date of injury, or from the last payment made on the claim, to file. Where the employer never filed a report of injury with the Division, that becomes three years. Deadlines are the one part of this that cannot be repaired later, so the sooner a denied claim is looked at, the more of it is still available.

When the Claim Is Open but Treatment Is Refused or Stalled

There is a particular kind of limbo in Missouri workers’ compensation, and if you are in it, you know it. The doctor the insurance company chose says you need an MRI, more therapy, a specialist or an operation, and then nothing happens. Nobody says no. Nobody says yes. The clinic is waiting on authorization, the adjuster says it is pending review, and the calendar keeps turning.

“A treatment plan on hold is not neutral. Bodies do not pause while paperwork does.”
Cynthia Hennessey, RN, JD

Who Picks Your Doctor in a Missouri Workers’ Comp Case?

Under section 287.140 of the Missouri statutes, the employer must provide the medical care reasonably required to cure and relieve the effects of the injury, and with that comes the right to choose the authorized treating doctor. It surprises almost everyone. It is also not the whole story.

• Authorized treatment is paid for by the employer or insurer, without your health plan’s copays or deductibles.
• You can see your own doctor as well, but generally at your own expense. What you should not do is quietly swap your doctor for theirs and stop attending authorized care. That reads as non-compliance and hands the insurer a reason to cut off benefits.
• In an emergency, get care first. Tell the employer promptly afterwards and keep a record of what happened.
• The authorized doctor’s views on causation, maximum medical improvement and your disability rating are opinions, not findings. They can be answered with an evaluation from a physician of your own choosing, and when one is needed the firm advances the cost.

Employer Selects, Doctor Recommends, Insurer Authorizes

That chain explains most stalls. The authorized doctor examines you and recommends the next step, but recommending is not ordering. The request goes to the insurer, which decides whether to pay for it, often after a review by a nurse, or by a physician who has never laid eyes on you. When treatment stalls it is almost always at that third link, which means the person holding things up is usually not the person who examined you.

“Pending review” describes the insurer’s internal paperwork. It is not a ruling, it does not come from anyone with authority over your claim, and it does not put your rights on hold.

“Calling the adjuster repeatedly is not the same thing as having a legal remedy.”
Cynthia Hennessey, RN, JD

If the adjuster has simply gone quiet, start with what to do when the adjuster won’t respond.

Put the Recommendation on Paper

Stalled care is won or lost on documentation, and this is where having a nurse on the file earns its keep. In her hospital years Cynthia watched plenty of verbal “let’s get some imaging” comments evaporate because they never made it into the chart. A recommendation that is not in the record is invisible to everyone who reviews the file later. A written order sitting unanswered is exactly the kind of paper a judge can weigh.

• MRI. Ask the office for a copy of the order or referral note. Without imaging there is no firm diagnosis, and without a diagnosis nothing behind it moves. More on what happens if you need an MRI.
• Physical therapy. When visits stop being scheduled mid-course, ask the clinic to note in your chart that the reason is authorization, and write it in your own log too. A gap documented as the insurer’s doing reads very differently from one that looks like yours.
• Specialist referral. The employer and insurer arrange specialists as well, so you usually cannot just book the orthopedic surgeon yourself. Get the referral in writing and record every request for a date. “Their doctor recommended it and they would not provide it” is a powerful sentence, if you can prove it.
• Surgery. Highest stakes, longest waits. Second opinions and records reviews can run for months. We cover both ends: what happens if surgery is recommended and what happens after surgery.

The Pattern With Delayed Surgery

The version Cynthia sees most often goes like this. The surgeon recommends the operation in early spring. By midsummer the worker is still calling the adjuster, unable to work, watching the season pass through the kitchen window. When the file finally lands on a desk with a hearing request attached, the authorization that could not be found for four months turns up quickly. The operation was never the obstacle. The absence of pressure was.

The Hardship Hearing: Missouri’s Answer to Stalled Care

Missouri saw this problem coming. When needed medical treatment or temporary total disability is being denied or delayed, a hardship hearing puts the dispute in front of an Administrative Law Judge without waiting out the ordinary pace of the claim. It is an evidentiary hearing, available under section 287.203 and the Division’s rule at 8 CSR 50-2.010(13), when a worker is not at maximum medical improvement, needs treatment, or is owed temporary total disability. We explain how a Missouri hardship hearing works in more detail.

The raw material of a hardship setting is the paper trail above: the authorized doctor’s written recommendation, a dated log of requests that went nowhere, and a file showing the insurer sat on its own physician’s advice. If the insurer has refused the care outright, start with what to do when the insurer won’t authorize treatment. The same route applies when the weekly checks stop while you are still off work, which we cover in what to do if your checks are late or stop.

“When workman’s comp told me I had hit the maximum amount they could pay, I called Hennessee and guess what… treatment was not longer denied! Don’t be jerked around, call Hennessee you will be pleased!”
Shannon Arthur-Baker, Rolla, MO, Google review

If Your Claim Was Denied in Illinois

The firm is licensed in Illinois as well as Missouri, and a good deal of our work comes from the Metro East. The process is similar in shape and different in its detail. Illinois claims go to the Workers’ Compensation Commission rather than the Division, and the filing deadline is generally three years from the date of injury or two years from the last compensation payment, whichever is later. If you were hurt in Illinois and denied, do not apply Missouri’s deadlines to your claim.

Talking to a Denied Claim Lawyer in St. Louis

There is no fee to have a denial looked at, and no fee unless we recover for you. What is useful to bring is the denial letter itself, anything the insurer has sent about an independent medical examination, and the names of the doctors who have treated you.

We are not a volume practice, and we will tell you plainly if a claim does not need a lawyer. If it does, you will be dealing with an attorney who has read the file.

Related pages: workers’ compensation, back injury, PTSD and psychological injury, spinal cord injury, nurse injury.