Workers' Comp Claim Denied? Your Options and Next Steps

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 are entitled to if they suffered a workplace injury and the 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.

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 workplace accident,” Lewis says. There are a few common reasons for denial:

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 claim could also get denied if you don’t file a claim with the insurance carrier within the required timeframe. This is typically 30-90 days. It is best to act quickly.

Preexisting Condition

If the 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

A claim could also be denied 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.

Determining if the Denial Is Correct

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

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 into 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 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 30-90 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 collect evidence.

“The most important component of a worker’s 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.”

Lewis emphasizes that “the purpose of the system is for people to get [help], and 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.”

Is It Easy To Fin a Workers’ Comp Lawyer?

How easy is it to find a lawyer for your workers’ comp claim? Lewis sheds light on this issue by looking at the financial incentives that lawyers have in different states:

“In states where the workers’ comp system works like filing a claim for a car wreck, there’s going to be a lot of lawyers that take those types of cases, and your access to representation is going to be fairly easy. In states where benefits are fairly restricted, the value of cases will be limited. Therefore, your access to lawyers will be more limited because there’s not enough money to make it worth hiring a lawyer.”

In states where workers’ comp claims are worth less, there may be “programs set up where people provide free assistance,” Lewis says, in addition to lawyers being available.

Find Legal Help

To find experienced workers’ comp lawyers in your area, visit the Super Lawyers directory and use the search box to find a lawyer based on your legal issue.