What to Do If Your Workers' Compensation Claim Is Denied in South Dakota

You have the right to appeal if your employer's insurance company rejects your workers' comp claim, but the process involves several steps.

You're entitled to workers' compensation benefits in South Dakota if your employer has workers’ comp insurance and you were injured on the job or got sick because of work. And if the insurance company rejects your claim, you have the right to challenge that decision with the state’s Department of Labor and Regulation (DLR).

The Workers’ Comp Dispute Resolution Process

There are a number of reasons your claim could be denied, including missed deadlines or having an injury that doesn't qualify for workers' comp. (See How to File a Workers' Comp Claim in South Dakota and Denied Workers' Comp Claims for details.) When that happens, South Dakota gives you two options for moving ahead: You can try mediation first, or you can immediately ask for a hearing with an administrative law judge (ALJ).

Workers' Comp Mediation

The mediation process starts when you submit a mediation request form. (The insurance company can also request mediation.) The process is voluntary and free, and it could help resolve the dispute in your case. You'll participate in mediation by telephone or in person, at a convenient location. The mediator will try to guide you and the insurance company to an agreement without taking sides.

If you come to an agreement with the insurer, one of you must send it to the DLR for review. The DLR should notify you within 20 days if it disapproves the agreement. Otherwise, the agreement will be binding and enforceable.

If you and the insurance company can't agree on a resolution, either of you can request a formal hearing.

Filing for a Formal Hearing

In order to request a hearing with an ALJ, you must mail a petition for hearing to the DLR within two years after your claim was denied. There's no fee for filing this petition. Your employer will then have 30 days to file an answer.

Discovery and Exchange of Information Before the Hearing

In a process known as "discovery," you'll be required to communicate with the insurance company to exchange information, including your medical records and other documentation. Most of the time, you (or your attorney) and the insurance company will make formal legal requests for this information; the ALJ may give you deadlines for turning over the requested records or documents. Additionally, there might be depositions where you, your doctor(s), and any witnesses will testify about your case. The judge may also order you to undergo a medical examination.

At a prehearing conference, you and the insurance company will spell out the disputed issues and give the judge a list of the witnesses who will testify at the hearing. Once both sides tell the ALJ that the discovery process is complete, you'll get a date for the hearing.

The Workers' Comp Hearing

Your hearing will be held in a convenient location in the community where your injury occurred. The hearing could last up to several days. You (or your attorney) and the insurance company make arguments, question witnesses, and present evidence. Once all the evidence is presented, both sides can either give concluding arguments or provide written arguments after the hearing. The judge will then make a decision on your case.

Appealing to the Secretary of Labor and State Courts

If you disagree with the ALJ’s decision, you can petition for review with the Secretary of Labor within 10 days. If you want to bypass this step, or if the Secretary denies your petition, you may appeal to the state Circuit Court, and then the Supreme Court of South Dakota.

Medical Benefit Disputes

After you and the insurance company have reached an agreement, or the ALJ has issued an order establishing your right to benefits, the insurer might still balk at paying for certain medical treatment. If the disputed medical bills are $8,000 or less, your can file for a small claims hearing (without a fee). This hearing will be conducted informally over the telephone.

If you don't want to use the small claims hearing process, or if the disputed medical costs are greater than $8,000, you can go through a full, formal hearing similar to the hearings for denied claims. To request this hearing, file a Medical Petition for Hearing with the DLR.

How to Get Help

To get general information about the workers’ comp process in South Dakota, you can call the South Dakota Department of Labor and Regulation (at 605-773-3681) or visit their website (where you can also download workers' comp forms).

If your claim has already been denied, however, you should strongly consider consulting with a lawyer who handles South Dakota workers’ comp cases. The dispute resolution and hearing process can be complicated, and the insurance company will rely on all of its resources (including attorneys) to try to deny you benefits. An attorney who’s experienced in this area can explain how the rules apply in your situation, help you gather evidence, represent you at the various stages of the process, and protect your rights. Learn more about What a Good Workers’ Comp Attorney Should Do and How Much a Workers' Comp Lawyer Costs in South Dakota.

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