NAC 616C.094(1)(a)-(b), within thirty (30) days after receipt of a
written request relating to a claim made by an injured employee, an employer,
a health care provider, or the attorney or other representative of any
of them . . . the insurer, third-party administrator, or organization
for managed care shall, in writing, notify the person making the request
of its determination concerning the request.
Workers’ compensation law in Nevada still operates via mail with
letters going back and forth from the injured worker or their much-needed
Attorney, and the insurance company. Every time an Attorney requests something
under the claim in writing, the insurer has thirty (30) days to respond
in writing approving or denying the request. This letter from the insurance
company is called a determination letter and will contain important appeal
rights for the injured worker, appeal rights that will expire in a short
seventy (70) day period.
What happens if the insurer simply does not respond? How often does this
occur? Unfortunately, it happens all too often, delaying the case for
often times no good reason. If the insurer does not respond, the non-response
operates as a “de facto” denial. However, this silence from
the insurer does not provide the injured worker with a definitive answer.
The only remedy the injured worker has is to file a notice of appeal and
present the issue before the Hearing Officer to get the insurer to respond.
However, by the time the injured worker gets into court, it could be forty-five
(45) to sixty (60) days later! Hopefully the insurer would have at least
responded by that time, but some do not.
The other remedy the injured worker could seek is filing a complaint with
the Division of Industrial Relations (“DIR”).
See NRS 616D.120. 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.
Id. But, DIR rarely fines insurers for failing to respond to written requests,
even if there is a distinct pattern of the same adjuster not responding
(or intentionally not doing their job).
Although this seems simplistic, it is not always. Injured workers should
seek an experienced Attorney regarding this circumstance. The experienced
Attorney will not only be able to give guidance on this process, but also
all other laws associated with work injuries.