If you sustained an injury or suffered an occupational disease while working in Idaho, you are probably entitled to benefits from your employer’s workers’ compensation insurer, including payments for medical treatments, lost wages, and permanent disability. (To learn about the benefits available, see Nolo's article on Idaho's workers' comp benefits.)
If the insurer wrongfully denies your claim for benefits, you can request a hearing before the Idaho Industrial Commission (IIC). You may represent yourself at the hearing, or you may hire a lawyer to represent you. However, because the issues involved in appealing a denial of benefits can be complex, you should consider hiring an attorney unless the dispute is simple or your injuries are minor.
In any event, before starting the appeal process, you or your attorney should review all of your medical records and conduct research on the legal issues involved in the denial of your claim. To learn some of the common reasons an insurer might deny your claim, see our article, Why Would an Employer Dispute a Workers’ Comp Claim?
To start the appeals process, you must file a legal document called a complaint. The IIC has a standard complaint form that you can use. You need to explain when and how the workplace injury happened, what medical treatments you received, what damages you are seeking, and when and how you gave notice to your employer. Finally, you must identify the factual or legal issues that are in dispute between you and the insurer.
You must file your complaint with the IIC and send a copy to your employer and its workers’ compensation carrier. The carrier will be required to formally respond to the issues raised in your complaint by filing a legal document called an answer.
Before the hearing, the parties have the opportunity to gather evidence to support their 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 (called interrogatories), requesting documents, and the taking of testimony under oath before a court reporter (called depositions). You can use these tools to obtain more information from the insurance carrier about why your claim was denied and how you can challenge the decision. You will also have to answer the insurance carrier’s questions and requests for information as well.
The IIC will appoint a commissioner to handle your appeal process. The IIC commissioner routinely schedules conferences, usually by telephone, throughout the discovery phase. These conferences monitor the status of the appeal and allow the IIC commissioner to determine if the parties would benefit from settlement discussions.
In most cases, the assigned IIC commissioner will suggest that you send your claim dispute to mediation, to see if it can be quickly resolved. Mediation is less formal than an appeal hearing, which more closely resembles a civil trial. The mediator facilitates discussion, and tries to help the parties reach an agreement, by offering an independent professional perspective of the merits of each party’s positions. If both you and the insurer reach an agreement on benefits in mediation, that ends your appeal. You can request mediation at any time during your case, but both parties must agree for mediation to take place.
If your attempts to settle the case aren’t successful, you must file a formal request with the IIC in order to schedule the actual hearing. The motion can be in letter format and must contain certain information, the factual and legal issues to be decided at the hearing, the party’s desired location and dates for the hearing, and a statement that all parties are ready to proceed with the hearing,.
The IIC hearing is similar to a civil trial, with the IIC commissioner conducting the hearing instead of a judge. However, unlike civil trials, there is no jury. The IIC commissioner alone will hear the case, make rulings on procedure and evidence, and determine what testimony and documents may be properly considered in reaching a ruling.
Like a civil trial, witnesses may be questioned and cross-examined by the parties or their attorneys. A court reporter will transcribe the proceedings. The length of the hearing varies, from a few hours to several days or weeks, depending on the number of witnesses, the scope of the disputes, the volume of evidence, and whether any expert testimony will be allowed (expert witnesses are individuals with specialized knowledge, such as doctors).
Once the parties have presented their cases, the IIC commissioner will review the admissible evidence. The commissioner can order the parties to submit additional legal briefs, if necessary. Similarly, the IIC commissioner may order that additional testimony be taken from witnesses or parties through depositions.
The IIC commissioner will issue a written decision as to whether you are entitled to benefits and in what amount. Typically, the written decision will be issued within 90 days from the last day of the hearing.
If you disagree with the written decision, you can ask the IIC, within 20 days, to reconsider. Your request must be in writing and include the reasons why you think the IIC should change its decision. The IIC will then provide you with a written ruling. If you are still dissatisfied after that ruling, you may file an appeal with the Idaho Supreme Court within 42 days. You can also directly appeal to the Idaho Supreme Court within 42 days of the hearing decision.
A successful appeal to the Idaho Supreme Court, however, requires detailed knowledge of the workers’ compensation laws and the court’s procedural rules. You should strongly consider hiring a workers’ comp attorney to represent you. An experienced attorney can also provide an estimate of the time and expense involved in this type of appeal.