Workers' Comp Denied? Your Next Steps

Workplace injuries are generally covered by an employer’s workers’ compensation insurance. This is an insurance program that benefits workers who have suffered a personal injury or illness due to their job. The insurance company handling the workers’ compensation benefits compensates injured workers. This financial assistance is used for lost wages, medical expenses, and other related costs.

But not all workers’ compensation cases are approved. Sometimes, the insurance company might deny a workers’ compensation claim. This can leave injured employees without help.

If your claim for workers’ comp is denied, you still have options. You may appeal the denial through your state’s board of workers’ compensation. However, there are various reasons why a claim may be denied.

This article will help you determine what steps to take if your claim for workers’ comp is denied. Keep in mind that specifics vary by state.

A local workers’ comp attorney can help you understand your rights and legal options under your state’s workers’ comp laws. Choosing to work with an attorney can strengthen your appeal and improve the chances of receiving the benefits you deserve.

Why Workers’ Comp Claims Are Denied

If your claim for workers’ comp was denied, the first thing you need to do is determine why. This should be explained in the denial letter. You may be denied if you do not meet the eligibility requirements. Still, you may appeal if you believe the denial was reached in error.

There are several reasons why an insurance company might deny a claim. Understanding these reasons can help injured workers better navigate the claims process. Common reasons for the denial of works’ comp benefits include:

• Non-work-related injury: If the insurance company believes the personal injury was not due to a work-related injury, they can deny the claim. For instance, they might reject the claim if the injury occurred outside of work or is due to a pre-existing medical condition.
• Employer disputes claim: Your employer may claim the accident was non-work-related. They might argue that the claim happened outside of work due to horseplay or some other disqualifying reason.
• Late reporting: Workers’ compensation laws require injured employees to report their job injuries. It should be reported to their employer within a particular time. The insurance company might only accept your claim if you report your injury in time. Check your state laws’ statute of limitations for workers’ compensation claims.
• Incomplete or inaccurate documentation: Providing insufficient information about your injury and medical care can result in claim denial. This might include incomplete medical records, inconsistent statements about the injury, or failure to provide requested documents.
• Failure to seek medical attention: If injured workers do not seek immediate medical attention after their injury, it can lead to claim denials. The insurance company might argue that the lack of immediate medical care implies the injury was not serious. You must obtain medical treatment to receive workers’ comp benefits. The bottom line: if you are hurt, seek medical care immediately.
• Injury is not compensable: Claims for stress-related injuries, for example, are difficult to prove in many states. By contrast, California workers’ comp laws specifically cover stress-related injuries.
• Discrepancies between medical reports and claims: If there are inconsistencies between what the claim says and what medical bills or reports indicate, the insurance company may deny the claim.

There are several other reasons why your workers’ comp claim may have been denied. In the event of a denied workers’ comp claim, injured workers have the right to appeal the decision.

Appealing a Workers’ Comp Denial

You may appeal the decision once you know why your claim was denied. This process typically involves filing an appeal. This appeal is filed with either the workers’ compensation commission or a similar agency your state may have. If the commission also denies the claim, the injury claim can be taken to the court of appeals.

The denial letter should provide a deadline for filing your appeal. The deadline is determined by state law. In Maryland, for example, you must file your appeal within 30 days of receiving the denial letter. Before you launch an appeal, you should meet with your employer to determine whether the dispute can be resolved. It could be a clerical error or a simple misunderstanding.

Appealing the decision can be a complicated legal process. An experienced workers’ comp attorney is best equipped to handle it. The appeal process can be complex and requires detailed knowledge of workers’ compensation laws.

It is essential to provide clear and consistent evidence to support your claim. This includes comprehensive medical records that show the extent of your injuries. The paperwork should also show the associated medical expenses.

The appeals process varies by state, but often involves a hearing before an administrative law judge. This may occur through the labor department or the state workers’ compensation board. There may be multiple levels of appeal, but it is essential to check your state’s laws for specifics. Talk to a legal professional for more help.

Get Professional Legal Help With Your Workers’ Comp Appeal

You may feel defeated by a workers’ comp denial letter, but you still have options. In many cases, you can successfully appeal your denial. But you may want to work with an experienced legal professional to ensure everything is handled correctly. Accepting a denial of benefits can be financially devastating, so you’ll want a strong ally in your corner.

An attorney can do more than provide legal advice. They can also:

• Help you understand your rights
• Recommend next steps
• Guide you through the appeals process
• Represent you in hearings or in court
• Communicate with the insurance company on your behalf

This can be very helpful when overturning a workers’ compensation denial. Working with an attorney increases your chances of a successful appeal.

Because state law is relevant, your lawyer should be licensed in the state where you work. FindLaw’s directory of workers’ comp attorneys can get you started. Select your state or city to review contact and ratings information for local experts. Your search results will also link you to additional details about the attorneys’ experience with workers’ comp and disability appeals.