What to Do If Your Workers' Compensation Claim Is Denied in the District of Columbia

Learn why insurance companies often deny claims for work-related injuries—and how you can appeal.

If you’ve suffered a work-related injury or illness in Washington, D.C., you’re entitled to benefits through the workers’ comp system, including medical expenses and payments for part of your lost wages. But what if your employer’s insurance company denies your claim or only approves partial benefits? This article explains common reasons insurers deny workers’ comp claims and how to file an appeal with the D.C. Office of Workers’ Compensation (OWC).

Common Reasons Insurers Deny Workers’ Comp Claims

Notify your employer immediately if you are injured on the job, and seek medical treatment as soon as possible. Your claim is more likely to be denied if you delay reporting the injury or seeking treatment.

In order to begin the claims process, you must also submit two official forms to your employer and the OWC. File an Employee’s Notice of Accidental Injury or Occupational Disease (Form 7) within 30 days of the injury, and an Employee’s Claim Application (Form 7A) within one year of the injury. Your claim might be denied if you don’t meet these deadlines. (For more details, see How to File a Workers’ Compensation Claim in the District of Columbia.)

Workers’ comp in D.C. only covers occupational diseases and accidental injuries “arising out of and in the course of employment” (AOE/COE), a legal term for injuries that happen because of the job and while the employee is actually working. Disputes over claims often hinge on the AOE/COE requirement. For example, your injury won’t be considered job-related if:

  • it happened because you were drunk
  • you intentionally hurt yourself, or
  • you were injured during the commute to or from work.

You also can’t receive workers’ comp benefits in D.C. if you’re already receiving benefits for the same injury under the workers’ comp system in any state (outside of D.C.).

These are only some of the reasons your claim could be denied. See Denied Workers Compensation Claims to learn more about other common reasons insurers deny claims.

How to Appeal a Workers’ Comp Claim Denial in D.C.

You have the right to appeal if the insurer denies your claim or doesn’t award the benefits that you requested. The OWC resolves claim disputes in D.C. There are three stages to the appeal process:

  • First, you need to file an appeal with the OWC’s Administrative Hearings Division (AHD), which will hold a formal hearing to determine your right to benefits. File an Application for Formal Hearing with the AHD and send a copy to the insurer. The AHD will then set a date for the hearing and issue a scheduling order. The order will include deadlines for taking certain actions; your application could be dismissed if you don’t meet those deadlines. You may be required to go to a physical exam as part of this process. At the hearing, each side will have the opportunity to present its case before an administrative law judge.(Learn more about what to expect at your workers' comp hearing.) The judge will review the evidence and issue a written decision.
  • If you aren’t happy with the judge’s decision, the next step is to file an appeal with the Compensation Review Board (CRB). You must file an Application for Review of a Compensation Order within 30 days after the decision. Your application could be derailed if you miss this deadline or don't meet the technical requirements, like submitting the original application along with three copies. You should also submit a memo explaining why the judge’s decision was wrong. The insurer then has 15 days to submit documents opposing your application and memorandum. A panel of three administrative law judges will review the evidence and issue its decision.
  • If the panel upholds the original decision, you may file an appeal with the D.C. Court of Appeals, within 30 days after the panel’s decision. This is the highest court in the district, so you have no other options if the court denies your appeal.

Do I Need A Lawyer?

The workers’ comp appeals process can be complicated and requires detailed knowledge of D.C. law, the Office of Workers’ Compensation, and the D.C. court system. If you haven’t already done so, you should consider consulting with an experienced workers’ comp attorney who can guide you through this process and protect your rights. Learn more about when you need to hire a lawyer for your workers' comp case and what a good workers’ comp attorney should do for you.

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