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

Learn why your workers' comp claim might be denied, and how you can appeal that decision.

If you have an on-the-job injury or become sick because of your work, you may be entitled to workers' comp benefits in New Jersey. But what if your employer’s insurance company denies your claim or doesn't approve all the benefits you expected? You have the right to challenge that decision. This article explains common reasons your claim might be turned down, as well as how to file an appeal.

Common Reasons Insurers Deny Workers’ Comp Claims

You could lose your right to benefits if you don't promptly notify your employer of your injury. In general, you must do this within 14 days after you were injured, but there are exceptions. The law bars benefits if you haven't made this report within 90 days, or your employer hasn't otherwise learned about the injury by then. In practice, however, you should give notice as soon as possible. The longer you wait, the more skeptical the insurance company will be about the validity of your claim.

If the insurer denies your claim, it's usually because the claims adjuster thinks you weren't injured as a result of work that you were doing for your employer. (Learn more about the rules for work-related injuries or illnesses.) Along with this general requirement, New Jersey law lists some specific situations in which workers' comp won't cover your injuries, including when:

  • you were hurt while participating in a voluntary recreational activity
  • you hurt yourself intentionally or through your own "willful negligence"

  • you contracted an occupational disease because you intentionally exposed yourself to a known hazardayou were hurt because you were intoxicated or using controlled dangerous substances

  • an injury happened because you started or participated in "horseplay" with coworkers
  • you were injured or became ill because you didn’t use the safety equipment your employer provided, despite multiple warnings that you should use that equipment; or

  • you had a heart attack, stroke, or other heart or brain-related injury at work, and you can't prove that it was caused by “work effort.”

How to Appeal a Denied Workers’ Comp Claim

You can challenge the insurance company's decision to deny workers' comp benefits, either completely or partially. You have two options for resolving a dispute:

  • File a formal claim petition with the the New Jersey Division of Workers’ Compensation (DWC). You must file this petition within two years after you were injured or after the insurer stopped paying benefits voluntarily. If you have an occupational disease (which includes conditions that develop over time, like repetitive stress injuries), the two-year period starts when you learned that your condition was related to your work. Within six months after you file the petition, you will have a hearing with a workers' comp judge. You'll have the opportunity to testify and present evidence.(Learn more about what to expect at your workers' comp hearing.) If you're unhappy with the judge's decision, you can file an appeal with the Appellate Division of the Superior Court in New Jersey.
  • File an application for an informal hearing with the DWC. If you don’t want to go through a formal proceeding, you can request an informal hearing before a workers’ comp judge. The judge will make suggestions but won't issue a formal decision. You can also use this process to address disputes about medical treatment and permanent disability benefits. If the informal hearing doesn’t resolve the dispute, you can still file a formal claim petition. However, the two-year filing deadline applies.

You can download the petition, application, and other workers' comp forms at the State of New Jersey Department of Labor and Workforce Development.

Medical or Temporary Benefits

The dispute resolution process might be too slow for injured workers who need immediate medical treatment and temporary disability benefits. If you’re in this situation, file a motion for medical and temporary benefits (either along with your claim petition or later, when the dispute about treatment or benefits comes up). The DWC will assign you an initial hearing date before a workers’ comp judge within 30 days.

Getting Help With Your Appeal

The claim dispute process can be complicated, and you can be sure that the insurance company will have a lawyer working on its side. If you want to help level the playing field and protect your rights, consider hiring a workers’ comp attorney who understands the complexities of New Jersey law and can help you navigate the appeals process. If you’re not sure whether you need an attorney, see Should I Hire a Workers’ Comp Attorney, or Can I Handle My Own Case? And to learn more about the affordability legal representation, see How Much Do Workers' Comp Lawyers Cost in New Jersey?

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