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

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’ comp benefits in Vermont if you were injured while working or got sick because of your job. And if your employer’s insurance company denies your claim, you have the right to challenge that decision with the state’s Workers’ Compensation Division (WCD).

Before we explain the dispute resolution process, it may help to understand some of the problems that can derail your workers’ comp claim, including:

  • Reporting and filing requirements. After you’re injured at work or learn that your medical condition is related to your job, you must tell your employer as soon as possible. Your employer is supposed to file a claim on your behalf. But if it doesn’t do that, you should file your own claim. You might lose the opportunity to get workers’ comp benefits if you don’t promptly report your injury or a claim isn’t filed within six months after the injury. (For more details on the claims process, see How to File a Workers' Compensation Claim in Vermont.)
  • Coverage disputes. The insurance company may argue that you aren’t eligible for workers’ comp benefits or don’t meet the requirements for a work-related injury or illness.

The insurance company has 21 days to accept your claim or send you a form explaining why it’s denying the claim completely or partially (for instance, by denying specific benefits or medical treatment).

The Workers’ Comp Dispute Resolution Process

You can challenge the insurance company’s decision to deny your claim by filing a notice and application for hearing (Form 6) with the WCD. Before you can actually get to a hearing, however, you’ll need to go through an informal dispute resolution process.

Informal Conference

After you file the hearing request, a WCD specialist will review the evidence (which you and the insurance company have submitted) and schedule an informal conference. You and the insurer's representative (and your lawyer, if you have one) will discuss the case, clear up any confusion, and try to resolve your disagreement. The specialist may ask for more evidence, schedule another conference, recommend or order the insurance company to pay workers’ comp benefits, or support the insurer’s original decision. If you disagree with the specialist’s decision, and more attempts at informal resolution aren't likely to succeed, the specialist will refer your case for a formal hearing.

Mediation or Arbitration

Before you get to the formal hearing, you may have to participate in mediation with the insurance company if the WCD decides that would be appropriate. You can ask to bypass mandatory mediation for certain reasons, including your inability to pay for it. The WCB might also order both sides to go to arbitration instead of a formal hearing.

Formal Hearing Process

If mediation is unsuccessful or isn’t required, an administrative law judge will first schedule a telephone pre-hearing conference to identify the issues, set deadlines for filing certain documents, and schedule a date for the formal hearing.

At the hearing, you and the insurance company will be able to present evidence, including medical records and examinations, as well as testimony from witnesses and doctors.(Learn more about what to expect at your workers' comp hearing.) The judge will issue a decision within 60 days after the end of the hearing.

Appeal to the State Courts

If you disagree with the hearing judge’s decision, you can appeal to the Vermont Superior Court within 30 days. (If the dispute deals only with the meaning of the law, rather than the facts in your case, you can appeal directly to the Vermont Supreme Court.)

How to Get Help

To get general information about the workers’ comp process in Vermont, you can call the Vermont Department of Labor (at 802-828-2286) or check out its website (where you can also download workers' comp forms). However, because contesting a denied claim can be a difficult and complicated process, you should strongly consider consulting with a lawyer who handles Vermont workers’ compensation cases. An attorney who’s experienced in this area can explain how the rules apply to the circumstances in your case, help you gather evidence, represent you at the various stages of the dispute resolution 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 Vermont.

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