If you've filed a workers' compensation claim after suffering a work-related injury or illness, waiting for a decision on your claim can be stressful. However, it helps to understand the workers' comp claims process and the timelines in your state. Some states set strict deadlines for claims processing, while others have looser guidelines.
In almost every state (except Texas), the vast majority of employers must have workers' compensation insurance coverage for their employees. Usually, companies either buy a workers' comp policy from a private insurance company or seek approval from the state to insure themselves. Because they will need to pay out accepted workers' comp claims themselves, self-insured employers typically must show that they have financial stability and significant assets. Once you file a workers' comp claim, the insurance company or your self-insured employer will either approve or deny it. (Many self-insured employers hire claims administrators to investigate and manage their workers' comp claims.)
However, four states—North Dakota, Ohio, Washington, and Wyoming—do not allow employers to buy insurance from a private company. Instead, employers must purchase insurance coverage directly from the state (or in some cases, self-insure). In these states, the state workers' compensation agency or a self-insured employer (or its claims administrator) decides whether an injured worker is eligible for benefits.
In all states, you must report your injury to your employer within certain time limits in order to receive workers' comp benefits. Some states also require the injured employee to file a workers' comp claim with the state agency before benefits can begin. Each state's notice and claim rules are different. If you do not follow the correct procedure, you may lose some or all of your benefits. To learn about your state's rules, choose your state from our filing a workers' compensation claim page.
Once your claim is initiated, the insurance company (or other decision maker) will investigate. The claims administrator will typically speak to you and your employer and review medical records, accident reports, and other documents. You should cooperate with the insurance company's reasonable requests for information and documents. But if you have any concerns about the investigation, contact a workers' comp lawyer. For example, it would be a good idea to speak with a lawyer if the insurance company is not returning your phone calls or you believe you are under surveillance.
In most states, the employer or insurance company must decide whether you're eligible for workers' comp benefits promptly or within a reasonable time period. Some states also have strict deadlines for approving or denying a claim—often between 14 and 30 days. In some states, the insurance company can ask for an extension of time if needed to investigate further.
If the insurance company fails to make a decision or request additional time within the deadline, it may have to pay a financial penalty. Or, in some states, your claim will be considered automatically accepted if you don't receive a decision in time.
In general, you should receive written notice that your claim was either approved or denied within a few weeks. If you haven't heard from the insurance company, you should contact your insurance adjuster or claims administrator directly. If you still do not receive adequate information, contact your state's workers' compensation agency or an experienced workers' comp lawyer. Some states also offer online portals where you can check your claim's status.
If your claim is denied, you may file an appeal with your state workers' compensation agency. You should receive a letter that gives a specific reason why your claim was denied. Depending on the reason, many denied claims can be appealed successfully. Each state has different appeal procedures and filing deadlines.
Before filing an appeal, it would be in your best interest to speak with a workers' comp lawyer. A lawyer can ensure that your appeal is properly filed in a timely manner and maximize the likelihood of winning benefits.