What to Do If Your Workers' Compensation Claim Is Denied in Florida

Learn how to appeal in Florida when your employer's insurer won't pay your workers' comp benefits.

If you’ve been injured at work in Florida, you may be entitled to workers’ compensation benefits. But what if your employer’s insurance company denies your claim or won't pay for all the benefits you believe you deserve? You have the right to appeal any decision that’s not in your favor. This article explains common reasons insurers deny claims and how to file an appeal with the Florida Division of Workers’ Compensation (DWC), which oversees the state’s workers’ comp system and reviews claim disputes.

Common Reasons Insurers Deny Workers’ Comp Claims

You could lose your right to workers’ comp benefits if you don’t give your employer notice within 30 days after you’re hurt at work or after a doctor tells you that your injury or illness is work related. (See How to File a Workers’ Compensation Claim in Florida for more details on the claims process.)

Your employer’s insurance company could also reject your claim if:

  • your work wasn't the cause of your accidental injury or occupational illness
  • you were injured because you were drunk or using drugs (other than legally prescribed medications), or
  • you intentionally hurt yourself.

If the accident happened because you refused to use an employer-provided safety device or follow safety regulations, your benefits will be reduced by 25%.

Learn more about the rules for deciding whether injuries or illnesses are work related and for workers’ comp claims filed after you’ve left your job.

Florida’s Workers’ Comp Dispute Resolution Process

You have the right to appeal if the insurer denies your injury claim or refuses to pay some Florida workers' comp benefits like medical bills or temporary disability. However, the state requires that you go through several steps first:

  • Dispute resolution conference. You must contact the DWC’s Bureau of Employee Assistance and Ombudsman (EAO) to ask for help resolving your dispute with the insurance company. The EAO may assign you an ombudsman to help you through the process. It may also order you to participate in a dispute resolution conference along with the insurance company, either by phone or in person. The goal is to find a way to settle the claim quickly. If you reach a settlement agreement, a workers’ comp judge must approve it.
  • Petition for benefits. If you aren’t able to reach an agreement with your employer’s insurance company, the next step is to file a petition for benefits with the Office of the Judges of Compensation Claim, with copies to your employer and the insurance company. You generally must file this petition within two years after you knew or should’ve known that your injury was work related. The petition must include a long list of specific information about your claim and your dispute with the insurer. A workers’ comp judge may dismiss your petition without a hearing if it doesn’t include all of the legally required information.
  • Mediation. After you file your petition, you’ll have to participate in an informal mediation conference within 130 days. Instead of using a state-appointed mediator, you and the insurance company may agree to private mediation. Information presented at the conference is confidential and won’t be disclosed without the agreement of both sides (even at a subsequent hearing). If both you and the insurance company agree in advance that the results of the mediation conference will be binding, neither of you may appeal those results.
  • Workers’ comp hearing. If mediation fails, you’ll participate in a final hearing conducted by a workers’ comp judge. Before the hearing takes place, there will be a pretrial hearing. You may also have to attend a deposition and answer questions from the insurance company. At the final hearing, you may present evidence, including testimony from witnesses. However, if you want to present medical reports as evidence, you have to give copies to the insurance company at least 30 days ahead of time. (Learn more about what to expect at your workers' comp hearing.) After hearing all the evidence, the judge will decide whether to grant or deny benefits.

Appealing a Workers’ Comp Order to the Court

If you’re unhappy with the results of the administrative hearing, you may appeal to the Florida’s District Court of Appeals, First District. You must file your appeal within 30 days after the workers’ comp judge’s order

Arbitration of Workers’ Comp Disputes

Instead of going through these steps, you and the insurance company may agree to binding arbitration. You must request approval for this step from a workers’ comp judge. You wouldn’t be able to appeal the arbitrator’s decision except in certain limited circumstances, so you should always speak to an attorney before you agree to binding arbitration.

Getting Help for Your Workers’ Comp Dispute

It’s frustrating when the insurance company denies your workers’ comp claim, balks at paying some benefits, or refuses to authorize medical treatment that you need. It’s also difficult to navigate the Florida workers’ comp system on your own—especially when it comes to appeals. If you don’t have an attorney, you can reach out to the EAO for information and assistance. You can also ask to have an ombudsman help you prepare a petition for benefits that meets all the legal requirements. However, EAO ombudsmen may not represent you at a workers’ comp hearing. And it wouldn’t be wise to go to a hearing without legal representation. So you should consider speaking to a workers’ comp attorney if you’re having disagreements with your employer’s insurance company—especially when you may need to request a hearing. If you haven’t decided whether to hire an attorney, see Should I Hire a Workers’ Comp Attorney, or Can I Handle My Own Case?

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