What To Do If Your Workers’ Compensation Claim Is Denied

Workers’ comp claim denials are far too common, although the rate of denials does vary by location. For example, one older national study revealed an estimated 7% of all workers’ comp claims are denied, while data from Oregon revealed a 10% denial rate in the state.

Unfortunately, claims are denied for many reasons, often because of mistakes. Here are some common reasons for denials, as well as some insight into why it’s so important to act swiftly if this happens to you.

Reasons for Workers’ Compensation Claim Denials

Here are some of the most common reasons claims are denied:

• The injury isn’t work-related or was a preexisting condition. If a workers’ comp insurer doesn’t believe the job was the direct cause of the harm or they believe you were already injured, they’ll deny your claim. Sometimes, it can be complicated to determine if an injury was work-related, such as if it happened while driving somewhere for your job or at a workplace event. In general, if you were performing job duties, then injuries you incurred should be covered.
• You failed to provide timely notice. You have a limited period of time to alert your employer when a work-related injury happens. If you didn’t submit notice of the injury on time or in accordance with your employer’s process, this could result in a claim denial.
• You didn’t get medical treatment or weren’t treated by an approved doctor. Some states require you to see a doctor on a list provided by your company to get treatment. There may be exceptions for dire emergencies, but seeing the wrong doctor could adversely impact your claim. If you don’t get treatment at all, you also typically won’t be able to get benefits because there won’t be documented evidence of the injury.
• You were intoxicated or engaged in horseplay at the time of the injury. Generally, your own negligence is not a factor that results in your claim being denied. However, if you were intoxicated at work at the time of the injury or were playing around and engaged in behaviors that were not work-related or against company policy at the time of the incident, this can give your employer grounds to deny your claim.
• Your employer doesn’t believe your claim was legitimate. If the company has other reasons to believe your claim is illegitimate, such as a suspicion you are lying about the cause of the injury or its severity, they may deny your work injury claim.

These are some of the most common reasons why employers and workers’ comp insurers may refuse to pay benefits on a workers’ comp claim that you make.

Common Mistakes Leading to Denials

Unfortunately, sometimes mistakes that you make could actually result in your claim being denied. Here are some common errors you’ll wait to avoid

• Not reporting your claim quickly. Failing to report your injury in a timely manner within any deadlines required by your state could result in a claim denial.
• Not getting prompt medical treatment. You should always see a doctor as soon as you are hurt or made ill by the performance of your work duties. Be sure the doctor documents all of your symptoms.
• Not seeing the right doctor. If your state or employer requires you to see an approved doctor, there should be a list of physicians at work. Pick from the list to avoid problems with your claim.
• Not disclosing all your symptoms. Downplaying the severity of your injury could result in your claim being denied or in not getting paid the full amount you should.
• Not getting legal help. Workers’ compensation claims can be complicated. It’s often best to talk with a lawyer right away when you’re hurt at work so you don’t make mistakes that could cost you.

Importance of Knowing Your Rights

You have rights if your claim is denied. You can appeal the decision and fight for the compensation that the law entitles you to receive.

However, you have a limited period of time to act. If you do not file your appeal within the allowable time, you may be unable to move forward with your claim.

You don’t want to lose the chance to recover your benefits, as workers’ compensation is generally your only option for getting paid by your employer after a work-related injury. State workers’ compensation laws generally prohibit you from filing a personal injury lawsuit in court.

A workers’ compensation lawyer will take swift action on your behalf so your appeal is submitted correctly and by the required deadline and you don’t lose your access to benefits.

After a workers’ comp denial, here are the steps you should take.

Determine the Reason for the Denial

You should find out from the employer or insurer why your claim was denied. Your denial letter should detail the reasons. If it was something simple such as a missing form, you may be able to correct the problem quickly by reaching out to the claims adjuster.

If there is a more serious issue, such as questions about whether your injury was work-related, then you’ll likely need to go through a mediation or appeals process.

Consider Alternative Dispute Resolution

In some states, there is a process for alternative dispute resolution after a workers’ comp claim denial.

For example, in Minnesota, the Department of Labor and Industry employs dispute resolution specialists who can help you resolve issues. The Department of Labor offers free mediation services, which allow you to go through an informal process with trained mediators who may be able to work with you and the insurer to find a compromise.

Appeal the Denial

If you aren’t interested in mediation, your state doesn’t offer it or mediation is unsuccessful, you have the right to formally appeal the denial. Your denial letter should tell you how to do that and explain the deadline by which you must appeal.

The process can vary somewhat by state, but it typically involves submitting an appeal to the Division of Workers’ Compensation or the Workers’ Compensation Commission where you live.

Request a Hearing

When you submit your appeal, you can request a hearing. This will usually take place before an Administrative Law Judge (ALJ) who works for the workers’ compensation board, division or commission in your state.

You’ll be notified of the date and place of your hearing and should prepare for it by gathering evidence and shoring up your arguments for why you deserve benefits.

Attend Your Hearing and Argue Your Case

You will need to attend your hearing before the ALJ either in person or virtually. You’ll have the chance to present your arguments and evidence and the insurer can do the same. You should have a work injury attorney at this meeting to help you to make the strongest possible arguments.

If the ALJ finds in your favor, then the appeals process is over and you’ll be able to access benefits. If that’s not the case, you can continue to move forward with additional steps in the appeals process.

Appeal to the Workers’ Compensation Appeal Board

If the ALJ denies your claim, you can generally submit a formal appeal with the Workers’ Compensation Board. You have a limited time to act and will need to submit evidence explaining why the administrative judge was wrong in denying your claim.

If this phase is unsuccessful, you still have one more option.

Appeal in Court

Finally, once you have exhausted your options for appealing within the Workers’ Compensation system, you are able to appeal to your state court.

This is usually the last phase of the process, although in some cases, you could appeal the initial court decision with a state appellate court or even a state supreme court.

At this phase, you will also have to demonstrate why the past decisions made by the ALJ and the workers’ compensation appeals board were not correct.

Appealing is the best option when your workers’ comp claim is denied. Here’s what you need to know about fighting for your benefits.

Understanding the Workers’ Comp Appeals Process

The workers’ comp appeals process is mostly handled with the workers’ compensation commission, division or board where you live. The phase of appealing may include:

• Appealing with an administrative law judge. This is a specialized judge who hears only workers’ compensation disputes.. The judge is part of the workers’ comp commission, division or board and is impartial. Judges hear cases, review evidence and make a decision on whether the workers’ compensation insurer acted properly. You’ll attend a hearing before the ALJ and present your case.
• Appealing to the workers’ compensation appeals board. If you are not satisfied with the decision made by the ALJ, you can appeal to the workers’ compensation board or commission within your state. This board or commission will review the decision of the ALJ to determine if a different ruling is appropriate.
• Appealing to the court. If you’re unhappy with the decision of the board, you will have the opportunity to appeal in court in your state. You’ll have to show why the decisions made within the administrative process were not appropriate. If your first court case is denied, you could potentially move up to appealing with your state appeal’s court or even the supreme court in your state, although the supreme court is not typically obligated to take cases.

Meeting Deadlines and Requirements

At every phase of the appeals process, you have a limited time to take action. The deadlines vary by state, and you’ll be notified of the time limit when you receive your denial or decision.

For example, in Pennsylvania, you must submit your appeal from the ALJ’s decision within 20 days.

Missing these deadlines may mean losing the chance to appeal, so you should work with an experienced attorney to ensure that you act within the allowable time to protect your rights.

Presenting a Strong Case in Your Appeal

When you appeal, you need solid evidence that the employer or insurer was not correct in denying your claim or you need solid evidence that the ALJ or workers’ compensation board acted improperly in affirming that denial.

Expert testimony may be required, as well as documented proof of your medical issues from a trained medical professional. An experienced workers’ compensation lawyer can help you to gather the evidence you need to appeal successfully.

Mediation and Alternative Dispute Resolution Options

If you don’t want to go through the full appeals process, you may be able to opt for alternative dispute resolution. Your state may offer assistance with this process in the form of providing a trained mediator who can assist you in resolving your conflict with the employer or insurer.

Alternative dispute resolution can sometimes be less stressful and a quicker option for deciding your claim. However, you don’t want to agree to anything that results in less benefits than you deserve because once you settle your claim, you usually cannot reopen it.

An experienced attorney can represent you during the appeals process and help you to maximize the chances of a favorable outcome.