What Happens if a Workers’ Comp Insurer Delays Benefits?

If a Virginia workers’ comp insurance company is late paying benefits it owes under an award, the law adds 20 percent to any payment more than two weeks late, unless the Commission finds the delay had good cause outside the employer’s control (Va. Code § 65.2-524). If there is no award yet, or the insurance company is stalling on a claim or a treatment request, the answer is the Commission: you can ask for a hearing no matter what the insurance company decides.

What you can do depends on why the money or treatment is late, and on whether you already have an award. Here is how to tell which situation you are in.

Why Workers’ Comp Benefits Get Delayed

The insurance company is required to pay a covered claim, but that doesn’t mean it will pay on time. Common reasons for a delay are a few of many:

• No claim has been filed with the Commission, so nothing forces a decision.
• The insurance company is “investigating,” waiting on medical records, or waiting for a recorded statement.
• There is a dispute over your average weekly wage, so nobody agrees on the amount.
• The Award Agreement hasn’t been sent, signed, or entered by the Commission.
• The insurance company sent you to an IME and is using the report to question your claim.
• It says you can do light duty, or that you turned down a job.

If You Don’t Have an Award Yet

Until there is an award, the insurance company may pay voluntarily, but there is no Commission order requiring it to pay you. That is why the first step is a filed claim. Once you file, the Commission will order the insurance company to respond within 30 days. It may accept the claim or deny it. If it denies the claim or doesn’t answer, you can ask for a hearing before a deputy commissioner.

File the claim even if the insurance company says it is accepting your injury. A claim must be on file with the Virginia Workers’ Compensation Commission within two years of your date of accident, although exceptions apply. Here’s how to file a workers’ comp claim.

If You Have an Award and the Checks Are Late or Stopped

An award is an order of the Commission. Once you have one, the insurance company can’t just stop paying because it decides you are better. To stop or reduce your checks, it has to file an application with the Commission (Va. Code § 65.2-708).

• A payment more than two weeks late gets the 20 percent addition, unless the Commission finds the delay had good cause outside the employer’s control (Va. Code § 65.2-524).
• If the checks stop without an application, you can ask the Commission for a hearing to enforce the award.
• If the insurance company defends a case without reasonable grounds, the Commission can make it pay the costs of the proceeding, including a reasonable attorney’s fee (Va. Code § 65.2-713).

If the Insurance Company Is Delaying Treatment

Medical delays work differently from late checks. The insurance company may sit on a request for surgery, an MRI, or a referral to a specialist, or deny it after a records review or an IME. The insurance company is required to provide medical treatment that is reasonable, necessary, and causally related to the accident (Va. Code § 65.2-603). When it won’t authorize that care, you can ask the Commission to order it.

What to Do While You Wait

• Check whether a claim has been filed. If not, file one.
• Write down every call with the adjuster: date, time, name, and what was said.
• Ask for anything important in writing, and send your own requests in writing.
• Keep your pay stubs and every out-of-work note from your doctor.
• Keep going to your doctor and following your restrictions. Gaps in treatment become the insurance company’s next argument.

Here’s when Virginia workers’ comp starts paying and what happens if your claim is denied.