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

Learn about your options when the insurance company rejects your claim for an on-the-job injury.

You’re entitled to workers’ compensation benefits in New Mexico when you’re hurt on the job or get sick because of your work. But what if your employer’s insurance company doesn’t approve your claim or denies some benefits? You can challenge that decision through a dispute resolution process with the New Mexico Workers’ Compensation Administration (WCA). This article explains that process, as well as some of the reasons claims are denied.

Common Reasons for Claim Denials

You could lose your right to workers’ comp benefits if you don’t meet New Mexico’s deadlines for reporting injuries and filing complaints. You must notify your employer in writing within 15 days after the workplace accident or after you learn that an injury or illness is related to your job. (For more details on the claims process, see How to File a Workers’ Compensation Claim in New Mexico.)

Even if you meet the reporting requirements, the insurance company will deny your claim if it thinks your injury doesn’t qualify for workers’ comp. In New Mexico, workers’ compensation covers only accidental injuries “arising out of and in the course of employment,” which means:

  • You were at work when you were hurt. This could be anyplace your job required you to be (like offsite training), but it doesn’t include commuting to or from work.
  • The accident was related to your job and led directly your injuries.

New Mexico law also rules out or limits workers’ comp coverage in some specific situations, including when:

  • employees hurt themselves on purpose
  • alcohol or drug use contributed to the injuries, and
  • employees were injured because they didn’t follow safety rules or use safety devices that their employers provided.

Learn more about the general rules for deciding whether injuries or illnesses are work related and other common reasons for denied workers' comp claims.

The Dispute Resolution Process

The insurer will notify you of its decision to approve or deny your claim. If you are unhappy with the decision, you can contact the New Mexico WCA Ombudsman Program. An ombudsman is a representative from the WCA who can help you resolve minor disputes with the insurer informally. If that doesn’t work, you must begin the formal dispute resolution process by filing a complaint with the WCA within a year after the insurer denied you benefits..

The dispute resolution process involves two levels:

  • Mediation. First, you’ll have to participate in a mediation conference. The mediator, a neutral third party, will listen to all sides and recommend a resolution. If both sides accept that recommendation (or neither formally rejects it within 30 days), the resolution will be legally binding.
  • Hearing. If you or the insurer rejects the mediator’s recommendation, your case will be assigned to a workers’ comp judge for a hearing. A workers’ comp hearing is a formal court proceeding, with procedures similar to those used in New Mexico district courts. The judge has the authority to issue subpoenas, require you to provide evidence, and examine witnesses and documentation.(Learn more about what to expect at your workers' comp hearing.) The judge will usually make a decision within 30 days after the hearing.

Appealing to the Courts

If you disagree with the workers’ comp judge’s decision, you can file an appeal with the New Mexico Court of Appeals within 30 days. After that, your only recourse is to appeal to the New Mexico Supreme Court.

Getting Help

The workers’ comp appeals process can be complicated and requires detailed knowledge of New Mexico workers’ comp law and the state’s procedural rules. The WCA’s ombudsmen can explain the process and provide informal help with minor disagreements. But ombudsmen aren’t advocates, and they can’t represent you during the formal dispute resolution process.

If you want to challenge an insurance company’s decision to deny your claim, you should strongly consider speaking with a workers’ comp lawyer. An attorney who’s experienced in this area can help you gather evidence and represent you at hearings. Even if you’ve missed the deadlines for reporting your injury or filing claims, a lawyer can explain whether exceptions in those deadlines may apply to your situation. Learn more about what a good workers’ comp lawyer should do and how much workers’ comp attorneys cost in New Mexico.

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