The Non-Response (De Facto) Denial

By Jason Weinstock on August 23, 2013

Injured workers have the right to file an appeal if the claims adjuster does not respond to a written request within 30 days.  Attorneys are usually the only ones that know that when the adjuster fails to respond, it is called a de facto denial, and a hearing officer can decide whether the requested benefits can be ordered.    What usually happens is that the injured worker who does not have an attorney waits and waits for the adjuster to respond to a request.  The request can be for any kind of benefit, such as a request to change doctors or a request for temporary total disability (TTD) benefits.  

NAC 616C.094 states that the adjuster must send a written response to any request from an injured worker within 30 days.  That regulation also states that the Nevada workers compensation adjuster must  include a form to file an appeal. Because the insurer is violating that regulation by not sending a written response, theoretically, the DIR should fine the insurer who doesn’t send a response on time.  But, DIR rarely fines insurers for failing to respond to written requests.   Instead, the injured worker will get quicker action by filing an appeal of  his or her non-response as follows:

1. Download and print a Request for Hearing form (or find one among the letters the adjusters has previously sent).

2. Attach a copy of the request letter you sent to the adjuster.  Make sure you don’t send this before 30 days have elapsed from your request letter or the appeal will be dismissed. 

3. Be sure you attend the hearing that will be scheduled about 3 weeks away. You can request to do the hearing by phone if you clearly ask for it and give your phone number.  

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