If you were injured on the job or developed a medical condition because of your work—such as a cumulative trauma like a repetitive strain injury (RSI) or lung disease from exposure to toxic chemicals—you’re no doubt hoping to be eligible for workers’ compensation benefits. But what can you do if your claim has been denied? The answer could depend on the reasons for the denial.
Employers or their insurance companies sometimes look for any possible reason to deny workers’ comp claims. Of course, that reason should be a valid one under the law. There are several common reasons for claim denials, including:
Don’t give up your right to workers’ comp benefits just because your claim was initially denied. First, look closely at the letter telling you that your claim was denied. It will probably include the reasons for the denial. If you think it was simply a matter of mistaken paperwork or something similar, you might consider contacting the claims adjuster to see if you can clear up the problem. But this route isn’t likely to be successful unless your employer or the insurance company made a bona fide mistake and admits it. More likely, you’ll have to consider appealing the denial.
The letter you received may include information about how to appeal the denial of your claim. If so, read it carefully. The appeals process varies in each state. Often, the first level of appeal will be at a hearing before an administrative law judge, where you’ll have to present medical and other evidence to support your claim. 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.
Unless your claim was denied due to a simple mistake that was immediately cleared up, it would be smart to speak with a workers' comp lawyer as soon as possible. An attorney can help you determine whether an appeal would be the best course of action for you. The timelines for workers’ comp appeals are short and strict, and you don’t want to lose your rights to benefits just because you missed a deadline.
Before you consider filing any appeal yourself, you should definitely talk to an attorney. Appeals are complicated legal processes, involving rules of evidence and civil procedure that the judge will expect you to know. If you don’t win at the initial levels, you may not be able to present additional evidence later in the process. One of the reasons that many injured employees lose their appeals is because they didn’t have an experienced workers’ compensation attorney at their side to help them prepare a strong case. Also, most workers' comp lawyers charge only a percentage of the benefits you actually receive, so it won't cost you anything unless you win.