Appealing an Alabama Workers' Compensation Denial
Learn what steps to take if you have a dispute in your workers' comp case in Alabama.
If you sustained an injury or developed an occupational disease while working in Alabama, you are probably entitled to benefits through workers’ comp, including payments for medical treatments, lost wages, and permanent disability. (To learn about the types of benefits available, see our article on Alabama's workers' comp benefits.) If you have a dispute in your workers’ comp case, you have two ways to try to resolve the issue.
Unlike most states, Alabama does not have an administrative court system dedicated to hearing workers’ comp disputes. In most other states, a worker can dispute a denial of a worker’s comp claim by filing an appeal with the state workers’ compensation agency. An administrative hearing would be held, and an administrative official would make a decision about whether your claim should be approved. However, in Alabama, this process is not available. Instead, an injured worker must file a lawsuit in state court to contest the denial of a workers’ comp claim. Because of the complexity of court procedures and Alabama workers’ comp law, you will probably need assistance from an experienced workers’ comp attorney to challenge a claim denial.
If you have a dispute about medical benefits only, you may also request assistance from the Alabama Department of Industrial Relations (DIR). The DIR has authority to hear and resolve disputes about medical benefits through its Ombudsman Program (described below). For example, if there is a dispute as to whether you need a certain type of medical treatment, the issue would be submitted to the DIR. For all other disputes, the DIR offers only limited assistance, primarily in the form of voluntary mediation services.
Help From the DIR
As stated above, the DIR does not have authority to make binding decisions when it comes to claim denials or other disputes that are unrelated to medical treatment. The DIR does, however, offer mediation services for non-medical disputes, if you and the insurance company both agree to participate. Mediation is an informal conference in which a DIR official will try to assist both sides in reaching an agreement. The DIR official only facilitates settlement discussions and will not make a binding decision regarding the dispute.
While the DIR’s voluntary mediation program may be useful for some disputes, it probably won’t be of much help if you are dealing with a claim denial. In practice, the insurance company will almost always decline to participate in mediation if it has denied your claim.
In 1992, Alabama passed a law to give the DIR authority to hear disputes about medical benefits for injuries occurring on or after January 1, 1993. The new law established a mandatory mediation program for medical benefit disputes called the Ombudsman Program. When there is a dispute about a worker’s medical treatment, the issue must be submitted to a DIR mediator (called an “Ombudsman”) who will conduct a conference to receive evidence on the matter. After the conference, the Ombudsman may also consult with independent medical experts before making his or her decision. The Ombudsman will then issue a decision that will be binding on all parties. For example, the Ombudsman may determine whether a specific treatment option should be authorized or whether the price of a certain medical bill is reasonable. In addition to the injured worker, a medical provider who has yet to be paid can also file a claim with the Ombudsman Program.
The Ombudsman Program is for medical disputes only and offers no assistance for disputes about coverage or other non-medical issues. For that you must turn to the state court. For example, an Ombudsman will not hear a dispute about whether an injured worker is an employee or an independent contractor, nor whether an employee willfully caused his or her own injuries by removing a safety device.
Filing a Civil Lawsuit
To dispute a wrongful denial of a workers’ comp claim, you must file a civil lawsuit in an Alabama District Court. Typically, you should file in the district in which you work for your employer or in the district in which your accident occurred.
A workers’ comp lawsuit is governed by the same procedural rules that apply to other civil cases. To file your lawsuit, you will need to complete a form called a “complaint,” describing the basis of your lawsuit. The complaint must state why you are disputing the insurer’s denial of your claim and what benefits you are seeking. Once the complaint is filed, the insurance company must submit a legal document called an “answer,” describing the reasons for denying your claim.
Once all of the paperwork has been filed, you and the insurance company will have the opportunity to gather evidence to support your positions. This process is called “discovery,” and it is governed by a set of formal rules and timelines. It may include exchanging written questions and answers, requesting documents, and taking of oral testimony under oath (called depositions).
Your case will be assigned to a Judge, who will normally handle all proceedings in your lawsuit, from any discovery disputes to pre-trial conferences. The assigned Judge will also receive the evidence and decide all issues at your trial. It may take months or years to reach trial, depending on the court calendar and the readiness of the parties.
You should also be aware that there is generally no right to a jury trial for your workers’ comp case under Alabama law. The one exception is if the insurance company has accused you of willful misconduct, meaning that your injury resulted from your intentional actions.
Finally, it is important to be aware of the strict time limits for filing your workers’ compensation lawsuit. If your claim was completely denied and you didn’t receive any benefits, you have only two years from the date of your work-related accident to file a lawsuit. However, if you received any disability payments (temporary or permanent), you have two years from the date of your last temporary or permanent disability payment to file a civil lawsuit.
Getting Help From an Attorney
Pursuing a lawsuit through the court system is complicated and requires detailed knowledge about workers’ comp law and both state and local procedural rules. For that reason, you should consult with an experienced workers’ comp attorney before filing suit to protect your interests.
Attorneys’ fees will usually be decided at the end of your lawsuit by the Judge assigned to your case. Under Alabama law, attorneys’ fees cannot be more than 15% of the award you receive.