Workers' Comp Claim Denied? Your Options and Next Steps
Be aware of the steps and deadlines in appealing a workers’ comp denial
on July 5, 2022
Employees who suffer work-related injuries could face significant financial strains due to required medical care or lost wages from missed work. Workers’ compensation benefits are designed to 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, what happens if a claim is denied and point toward further legal help.
What Workers’ Compensation Is
Workers’ comp provides “medical treatment and income replacement benefits to employees who get hurt on the job,” says Texas workers’ compensation attorney Matthew Lewis. “There are workers’ compensation systems nationally, and each state has its own workers’ compensation laws as well.”
Generally, workers’ compensation laws specify:
- Benefits employees are entitled to if they suffered a workplace injury
- Procedures for claiming these benefits
What kind of benefits can injured workers get? While every state workers’ comp system is different, Lewis says there are generally three kinds of benefits:
- Income replacement benefits for employees who have to miss work due to their injuries
- Medical benefits that help people get the medical treatment they need
- Impairment benefits that help compensate employees for permanent or long-term damage
Reasons That 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 (generally within a few days) or file a claim with the insurance carrier within the required timeframe (typically, 30-90 days). It is best to act quickly.
- Preexisting condition. A claim could be denied if the insurance company believes that the injury or illness predates the incident on the job site.
- 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 is on the job site and then 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.
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.
The Workers’ Compensation Appeals Process
When a workers’ comp claim is 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.
Depending on where you live, the appeals process could be a multi-step system. For example, “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
We saw above that 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.”
Finding a 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.
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.
Questions for an Attorney
The process for filing a workers’ comp claim can be very complicated. If you are pursuing workers’ comp or an appeals process, consider speaking with a workers’ comp lawyer for legal advice about your claim.
Many attorneys provide free consultations to prospective clients. These consultations allow the attorney to hear the facts of your case and for you to determine if the attorney meets your needs.
To see whether an attorney or law firm is a good fit, ask informed questions such as:
- What are your legal fees, and what billing options do you offer?
- What is your experience as a workers’ comp attorney?
- What are the deadlines for filing a claim and appealing denials?
- How much money could I expect in a settlement?
- Is a settlement likely?
Look for a workers’ compensation attorney in the Super Lawyers directory to help with workers’ comp issues.