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

Learn why your employer's insurance company might refuse to pay benefits for your work-related injury or illness, and how you can appeal that decision.

Georgia gives you the right to workers’ compensation benefits when you have a work-related injury or an occupational disease. You also have the right to appeal if your employer’s insurance company says you don’t qualify for benefits. This article explains the procedures for resolving workers’ comp disputes in Georgia, as well as some of the reasons your claim might be rejected.

Common Reasons for Denying Workers’ Comp Claims in Georgia

If you don’t tell your employer about your injury within 30 days, you could lose your right to collect the workers’ comp benefits available in Georgia. However, there are exceptions to this rule, such as when your employer actually knew about the accident.

An insurance company will reject your claim if it doesn’t believe your injury qualifies for workers’ comp coverage. The general rule is that you must have had an accidental on-the-job injury that was caused by your work. Georgia workers’ comp also covers occupational diseases that directly result from exposure on the job, as well as diseases that are an unavoidable result of the original injury. Learn more about the basic rules for deciding which injuries or illnesses are work related.)

Georgia law specifically rules out workers’ comp coverage for injuries that happen under certain circumstances, including when:

  • you intentionally hurt yourself
  • your injuries resulted from your own misconduct, such as refusing to use a safety device, trying to hurt someone else, or being under the influence of alcohol, marijuana, or a controlled substance that wasn’t prescribed
  • someone else hurt you on purpose for personal reasons, or
  • you had a heart attack, stroke, or similar condition, unless the evidence proves that it resulted from your normal work activities.

How to Appeal a Denied Workers’ Comp Claim in Georgia

In Georgia, the State Board of Workers’ Compensation (SBWC) reviews any disagreements over workers’ comp claims. There are several stages to the dispute resolution process.

Filing the Notice of Claim

In order to challenge an insurance company’s refusal to approve your claim or some of your benefits (like needed medical treatment), you first must file a “notice of claim” (form WC-14) within one year after your injury. If the insurer has already paid for some benefits, the deadline is one year after the last medical treatment it provided, or two years after the last weekly disability payment.

You can download the WC-14 from the forms page on the SBWC website. You can use the same form to request mediation or a hearing. Mail the completed notice to the address listed at the bottom of the form.

Mediation

The workers’ comp judge may order you to participate in mediation, either on its own or because you or the insurance company has requested it. If you aren’t able to reach a settlement agreement with the insurance company after mediation, your dispute will proceed through the appeals process.

Workers’ Comp Hearing

A workers’ comp hearing will usually take place in the county where the injury happened. Although these hearings are generally informal, they’ll follow the same rules as in regular civil cases for gathering and presenting evidence, including testimony from witnesses. You (or your attorney) will also be able to make legal arguments and cross-examine the insurance company’s witnesses.(Learn more about what to expect at your workers' comp hearing.)

The judge will review the evidence and make a decision within 30 days. You’ll receive a copy of the decision by mail.

SBWC Appellate Review

If you’re unhappy with the results of the hearing, you may appeal the judge’s decision to the appellate division of the SBWC. You must file your application for review within 20 days after the decision was issued. If the insurance company appeals, you can file a cross-appeal within 30 days of the judge’s decision. Typically, the appellate division will make a ruling after reviewing both sides’ written arguments. But you (or the insurance company) may request an in-person hearing. The appellate division might also decide to send the case back the workers’ comp judge to reconsider the case or hear additional evidence.

Appealing to the Courts

If the SBWC rules against you, you may take your appeal to Georgia’s court system. You must file your appeal in the county where you were injured, within 20 days after the SBWC’s final order. If you’re still unsatisfied after the superior court considers your claim, you may petition for review before the Georgia Court of Appeals.

Contact a Lawyer About Your Disputed Claim

Injured workers have enough to worry about without having to navigate the appeals process on their own. If you’re having trouble collecting workers’ comp benefits from your employer’s insurance company, consider hiring an attorney who is experienced in Georgia workers’ comp law to represent you in your appeal with the SBWC and, if necessary, in state court. If you’re on the fence about whether you need an attorney, see our articles on when to hire a workers’ comp attorney and what a good workers’ comp lawyer should do for you.

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