Can I Appeal if My Workers' Comp Claim Is Denied?

Employees who suffer work-related injuries could face significant financial strains due to medical care or lost wages from missed work. Workers’ compensation benefits help injured employees recover from their injuries while remaining financially afloat.

However, the process for claiming workers’ compensation benefits can be complicated. This is especially true if an employee’s claim is initially denied by an employer or insurance company.

This article will explain the general process for pursuing a workers’ comp claim and what happens if a claim gets denied. For legal help, contact a local workers’ comp lawyer.

What Is Workers’ Compensation?

“Workers’ comp provides medical treatment and income replacement benefits to employees who get hurt on the job,” says Matthew Lewis, a workers’ compensation attorney at MLF Legal in Dallas, Texas. “There are workers’ compensation systems nationally, and each state has its own workers’ compensation laws as well.”

Generally, workers’ compensation laws specify the benefits that employees get if they suffer a workplace injury. State laws also have specific procedures for claiming these benefits.

While every state workers’ comp system is different, Lewis says there are generally three kinds of benefits:

1. Income replacement benefits for employees who have to miss work due to their injuries
2. Medical benefits that help people get the medical treatment they need
3. Impairment benefits that help compensate employees for permanent or long-term damage

Reasons Why a Workers’ Comp Claim Could Be Denied

If your employer or insurance company denied your workers’ compensation claim, the first important step is to learn the reason for the denial.

When Cathy M. Stanton first came to workers’ comp law, New York had an easily navigable system for injured employees. “But that’s not the case anymore,” she says. “We often get contacted at the onset of the case because of the myriad of hurdles and bureaucratic obstacles placed in front of the worker in New York State.”

The denial letter should explain the reasoning for the decision. Workers’ comp claims are generally denied “if an insurance adjuster believes the injury does not arise out of a work-related accident,” Lewis says.

Some common reasons for a denied claim include:

• Minor mistakes on the application paperwork
• Not reporting the accident on time
• Missing deadlines
• Failure to seek professional medical treatment
• Insufficient medical evidence
• Disputes about the existence or severity of the medical condition
• Disputes regarding when and where the accident occurred
• Errors or bad-faith settlement practices by insurance companies

Didn’t Meet Deadlines

Deadlines are crucial throughout the entire workers’ comp process. Your claim could be denied if you do not promptly report an injury to your employer. You generally have a few days to do this.

The most important steps if you’re injured are to: give immediate notice to your employer, seek immediate medical treatment, and file your claim before the statute of limitations runs out. If you follow these three steps, Stanton says, you’re giving your claim the best possible shot at approval.

If you were injured on the job, comp benefits are available for medical costs and lost wages. Unfortunately, recovering workers’ compensation is not always easy. Unfair denials happen. If your employer rejected your workers’ comp claim, do not give up. You have the right to file an appeal.

The claim could also be denied if you don’t notify your employer within the required timeframe (typically 30 to 90 days), or if you fail to file a formal claim before the statute of limitations expires (typically 1 to 3 years). It is best to act quickly.

Preexisting Condition

If the workers’ compensation insurance company thinks your injury or illness predates the workplace incident, they could deny your claim.

Injury Is Not Work-Related

“Maybe there’s a question about whether the event that occurred was in the scope and course of employment,” Lewis says.

For example, perhaps an employee goes to lunch and gets in a car wreck. Or the employee is on the way to work from home and gets in an accident during the commute. Do these incidents count as work-related injuries? Lewis says that “a lot of variables can come into play.”

Lack Coverage

Another reason could be that the employer doesn’t have coverage for an employee or a particular worksite.

“There are a lot of companies that play games with coverage,” Lewis says. “For example, they will purchase workers’ comp insurance for the one secretary in the office but not for the 150 workers on scaffolding out at the different job sites.”

Intoxication

The insurance company could also deny a claim if a drug test comes back positive for alcohol or some level of marijuana, cocaine, or another illegal substance, causing impaired judgment.

Review Your Denial Letter for the Specific Reason

These are only some of the reasons for denied workers’ comp claims. Reviewing the denial letter for the specific reasons in your case is essential. If the reasons are unclear from the letter, speak with your employer directly.

“Your claim can be denied for a number of different reasons, but that doesn’t mean that’s the end,” Stanton says. “It just means it has to go before a law judge, who ultimately has to make the decision. If they make a decision that either side isn’t happy with, then there’s an appeal process.”

Determining if the Denial Is Correct

When a workers’ comp claim gets denied, the employee must first determine if the denial is correct. “Employees will need to consult with a workers’ compensation lawyer or someone in the state who’s versed in that state’s compensation system,” says Lewis.

If you think the denial is wrong, you must pursue the dispute resolution process available within your state. Typically, state law requires that workers’ comp denial letters explicitly state the deadline for filing an appeal.

The Workers’ Compensation Appeals Process

Depending on where you live, the appeals process could be a multi-step system. “Maybe mediation with the insurance company has to occur first,” Lewis says. “If you don’t get the problem resolved in mediation, you then have to go through some type of administrative hearing. This is just like going to trial, but with an [administrative law judge] only, not a jury, and you get a decision from the judge on how it will play out.”

Once you get a decision from the judge, “there can be different appeals – maybe you can appeal the decision in the court system.”

Whatever appeals strategy you pursue, Lewis says, “the bottom line is that once your employer denies the claim, you have to do something proactively to pursue that claim.”

Lewis says that acting quickly is the way to go. “Everyone’s memory is fresh, medical records are fresh, and you’re probably still getting medical treatment – so there’s ongoing medical report evidence that will help you prove your claim.”

The Importance of Deadlines

Deadlines are important from the very beginning of a workers’ compensation case. That is true of the appeals process as well. “Deadlines are critical because most of the time, if you miss a deadline, your entire claim gets wiped out,” Lewis explains. From initially reporting a claim to appealing a denial to having mediation to going to trial, each stage has a deadline.

If you miss one of these deadlines, “Your claim is over with respect to whatever issue was being litigated. In some states, you can lose your entire claim; in others, you just lose out on the issues that were being litigated at the time.”

Most of the deadlines in the appeal process fall within the 30 to 60-day timeframe. It is essential to be aware of each one to avoid losing out on any part of your claim.

Preparing for Success in Your Workers’ Comp Claim

If you are pursuing a workers’ comp claim, one of the most important things you can do to set yourself up for success is to collect evidence.

“The most important component of a workers’ comp claim is the evidence that backs up your story,” Lewis says. “When the medical record and your testimony before a judge are different, the judge tends not to believe the story you’re telling. And when that happens, they will rule against an injured worker.”

“The purpose of the system is for people to get help,” says Lewis. “There’s supposed to be a liberal [interpretation] of workers’ comp rules to favor coverage for injured workers. So, the very least you can do to help yourself is to make sure that the doctor’s reports and the story of what happened to you, in reality, match up. If you can make that happen, that sets the foundation for the remainder of your claim.”

Finding a Workers’ Comp Lawyer?

“The insurance company is representing your employer,” Stanton adds. “If they have someone looking out for them, you want an even playing field, which means having an attorney representing your best interests.”

“If you’re injured, you should contact an attorney so they can at least explain your benefits and what you’re entitled to. I always tell people when they call that it’s important to be grounded and have an understanding of their rights,” says Michael F. Scully, a workers’ comp attorney with SiebenCarey law firm in Minneapolis.

If a claim is denied and you retain an attorney like Scully, “I’ll set up a time for a face-to-face meeting and ask them to send me the necessary documents,” he says. “Then we’ll file a claim petition, which is the equivalent of filing a lawsuit in district court. An unrepresented person can do it on their own, but it’s a real maze if you don’t understand what to do.”

Attorneys in this field work on a contingency fee basis, meaning “we don’t get paid unless the injured worker gets paid,” Stanton says. “In New York, our fee is paid directly by the insurance company, so never should a worker be writing a workers’ comp attorney a check.” The judge approves fee requests, and while the law doesn’t specify an amount or range, it’s commonly around 15 percent.

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