If you are injured on the job, whether in a work-related injury or by a cumulative trauma (like carpel tunnel) or occupational disease (like asbestosis), you most likely have a workers’ compensation claim in your state. However, workers’ compensation claims may be denied for many reasons, as described below. If you workers’ compensation claim is denied, you will receive a letter stating the claim was denied. The letter will likely state the reasons your claim was denied.
Common Reasons for Claim Denial
One of the most common reasons that workers’ compensation claims are denied is that the claim was not reported or filed on time. The law requires that a worker report the claim immediately, sometimes within a matter of days. And the employer must inform the state and/or their workers’ compensation insurance carrier just as quickly.
Another common reason is that the employer disputes the claim. This can be because the employer disputes the accident ever happened at work, or disputes that your current injury/illness is a result of the accident (or exposure or overuse). If this is the case with your claim, you will need to gather additional evidence to support your workers’ compensation claim. This can be witness accounts that the accident occurred or a statement from your doctor attributing your condition to your workplace.
The employer or its insurance company will sometimes look for whatever reason possible to deny a workers’ compensation claim. For an employer, denying a claim means decreasing insurance expenses and liability.
There are several other reasons a claim may be denied. Some states preclude certain conditions as workers’ compensation claims, such as stress-related conditions. Or, your injuries might not be severe enough to amount to a workers’ compensation claim. Look at your claim denial letter for the reason(s) your claim was denied, and talk to an attorney if you are still uncertain why your claim was denied.
Appealing a Workers' Compensation Claim Denial
The letter you received stating your workers’ compensation claim was denied may also describe how you can appeal the denial of your claim. Make sure you read the letter carefully, and note any appeal deadlines.
The first step to consider is contacting your employer or its workers’ compensation insurance carrier to discuss your claim denial. If the denial was simply a matter of mistaken paperwork or other similar problems, the mistake could be cleared up and your claim allowed. But this route is unlikely to be successful unless your claim denial was a bona fide mistake on the part of your employer or its insurance company. If your employer still refuses to allow your claim, you may want to appeal the claim denial.
The appeals process varies in each state. Often, the first level of appeal will be at an administrative hearing before an administrative law judge. The hearing can be through a state labor department or a state board of workers’ compensation. There are additional levels of appeal beyond the initial administrative levels as well, which vary depending on the state.
At the appeal hearing, you will be required to present medical and other factual evidence to support the existence of your workers’ compensation claim, whether it is a work-related injury or occupational disease. Make sure that your appeal is filed within the time limits, and that you have plenty of medical evidence to support your claim.
Talk to an Attorney
Do not give up your right to workers’ compensation benefits simply because your claim is denied initially.
Talk to a workers' comp lawyer as soon as possible. An attorney can help you determine whether an appeal of your workers' compensation claim denial is the best course of action for you. Appeal deadlines are short and strict, and you do not want to lose your rights to your workers’ compensation claim.
And you should talk to an attorney before filing any appeal yourself. Appeals are complicated legal processes, involving rules of evidence and civil procedure that the judge will expect you to know. If you do not prevail at the initial levels, you may not be able to present additional evidence at subsequent appeal levels. One of the reasons that many people lose their workers' comp claim appeals is because they did not have an experienced workers’ compensation attorney at their side to help them prepare a strong case.