What To Do if Your Workers' Compensation Claim is Denied

What To Do if Your Workers' Compensation Claim is Denied

After you have been injured on the job, you expect to receive your benefits to help with medical costs and income losses. However, there are times when your claim can be denied. In these cases, you have a few options to appeal the workers’ comp decision.

If you would like to know what to do if your workers’ compensation claim is denied, here are a few points you will want to know.

Workers’ Comp Decisions

According to the National Safety Council, workplace illnesses and injuries totaled 4.53 million in 2022. Workers’ compensation is there to help bridge the financial gap when you are hurt on the job. When injured workers file for benefits, they expect to receive them. But that is not always the case, and your claim could be denied.

Once you submit your workers’ compensation claim to your local state board, you must wait for a decision. You will either receive approval or a denial. If you get a denial letter, that is not the end of the line. You have a right to appeal. However, the first step in these cases is to closely examine the letter.

That letter should explain why your request for workers’ comp was denied. It will outline the reason for the denial, your right to dispute the decision, and how to appeal it. This letter is very important for the next step of the claim. You will want to keep it and refer to it as you proceed through this process.

Understand the Reason Behind the Denial

Many times, there is a straightforward reason for your denial. That could be due to a missed deadline or a lack of medical evidence. Your denial letter will outline the issue with your initial claim. Now that you know the problem, there may be ways to resolve it by appealing your case.

If the insurer claims insufficient medical evidence, you will want to collect all the evidence and documents related to your injury and treatment. This can include everything from the initial doctor’s records to diagnostic tests and follow-up care details. You may want to talk to your physician about obtaining a detailed report regarding your injury or illness. If the documents are vague or do not focus on how your job may have caused the issue, that can lead to a denial.

Unfortunately, sometimes, you can miss an important deadline to file.  A lack of awareness about the requirement, misinformation, or other extenuating circumstances, such as hospitalization or incapacity, are all reasons situations like these occur. You will want to account for the reasons for the delay. Take this time to gather your hospital records or proof of communication that led to the misunderstanding. Presenting a legitimate and documented reason for a missed deadline can sometimes result in leniency from the insurer.

One of the most common reasons for a denial is the dispute about whether the injury or illness is job-related. If the insurer cites pre-existing conditions, you need to review your medical records to understand why the insurer may try to link your current health issue to a pre-existing condition.

You may need to work with your doctor to produce evidence of how your job tasks aggravated or worsened your pre-existing conditions. A clear connection between your job duties and the deterioration of your health can support your claim. Your health care provider can also explain how your current condition is related to or exacerbated by your workplace environment.

The illness or injury needs to be connected to your work duties to get workers’ compensation. In some situations, the insurer can dispute the cause. With that, you will want to collect all evidence showing a link between your health condition and workplace activities. These can include:

  • Witness statement
  • Photographic & video evidence
  • Incident reports
  • Activity logs

With all this evidence in hand, you can counter the insurer’s objections and give sufficient support to your claim. After following these steps, you can either pursue the appeal on your own or hire an attorney to handle your claim.

File an Appeal

Once you know the reason for the denial and have gathered all the evidence, you can start the process of the appeal. Remember that each state will have its own forms and deadlines to meet. You will want to make sure they are filled out completely and accurately. Otherwise, your appeal could be denied.

After sending in the form, you have a hearing date. During this time, you will need to explain your case and present all relevant evidence to the judge or board. You will want to be prepared to answer all questions they ask about your incident, injury, and medical treatments you’ve received as well as your work history.

What Happens If Your Claim Gets Denied Again?

If you receive a second denial, you can start the process over and file a new application for benefits. However, you also have the option to take your claim to federal district court. This court will look for administrative or legal errors. If they agree some exist, the lower court’s decision could be reversed. But if the appeal of your workers’ compensation claim is denied, then that ruling will stand.

Information for Workers' Compensation Claims

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This website was created and is maintained by the legal team at Thomas Law Offices. Our attorneys are experienced in a wide variety of personal injury and work injury cases and represent clients on a nationwide level. Call us or fill out the form to the right to tell us about your potential case. We will get back to you as quickly as possible.