If you have a work-related injury or illness, you may be entitled to workers' compensation benefits in Tennessee. But your employer’s insurance company could deny your claim or only approve partial benefits. What options do you have if that happens? This article explains common reasons insurers deny claims and how to file an appeal with the Tennessee Bureau of Workers’ Compensation (BWC), the agency that oversees the state workers’ comp system and reviews claim disputes.

Common Reasons Insurers Deny Workers’ Comp Claims

You should report your injury as soon as you can to your employer. If you don't do so within 15 days after the accident, you could lose your right to workers' comp benefits unless you have a good excuse. When you have an occupational disease or an injury that developed over time (a "cumulative trauma" like carpal tunnel syndrome), the notice deadline is 15 days after:

• the injury keeps you from doing your normal job duties, and you know or should know that the injury is work related; or
• you've learned that you have permanent limitations because of a work-related injury.

(For details on what happens after you report your injury, see How to File a Workers’ Compensation Claim in Tennessee.)

Your employer's insurance company will deny your claim if it believes that your injury didn't meet the state's requirements for workers' comp coverage. In Tennessee, your job must be primarily responsible for the injury or occupational illness (meaning more than 50% out of all causes). Although workers' comp is generally a "no-fault" system, Tennessee law rules out coverage when injuries result from certain kinds of misconduct, including when employees:

• are drunk or using illegal drugs
• refuse use a safety device, or
• hurt themselves on purpose.

Also, workers' comp generally won't cover injuries that happen when employees are participating in voluntary recreational activities sponsored by their employers.

How to Appeal a Denied Workers’ Comp Claim

If the insurer denies your workers’ comp claim or doesn’t approve all of the benefits you expected, you should file a Petition for Benefits Determination form with the BWC within one year after the accident.

Workers' Comp Mediation Services

The first step in the appeals process is mediation. A neutral third party, called a mediation specialist, will try to help you and the insurance company resolve the dispute, including a disagreement about permanent disability benefits and medical treatment needs.

If you and the insurance company reach an agreement, a workers' comp judge must approve your settlement agreement. If you don't come to an agreement, the mediation specialist will file a Dispute Certification Notice.

Hearing with Court of Workers' Compensation Claims

After you've gone through the mediation process and the specialist has filed the Dispute Certification Notice, you may request a hearing with a workers' comp judge. But you must make this request within 60 days after the notice was filed.

The judge will consider the evidence, including testimony from witnesses. After the hearing, the judge will issue a compensation order. You then have 30 days to file an appeal with the Workers' Compensation Appeals Board if you disagree with the order.

The judge may also issue interim orders (such as an order for your employer to pay for medical treatment or temporary disability benefits). If you want to challenge on of these orders, you must file an appeal within seven days.

Appeals Board Review

After you appeal the judge's decision, the Workers’ Compensation Appeals Board will decide whether to affirm, reverse, or modify the order. If you’re unhappy with the board’s decision, your last option is appealing to the Tennessee Supreme Court.

Reach Out to a Lawyer or an Ombudsman

The appeals process can be challenging to go through alone. You can request assistance from the BWC’s Ombudsman Program. An ombudsman can give you information about workers' comp procedures and help you fill out form. But an ombudsman cannot give you legal advice. So if the insurance company has denied your claim, consider consulting with an experienced workers' comp attorney. If you’re not sure whether you need a lawyer, see Should I Hire a Workers’ Comp Attorney, or Can I Handle My Own Case?