If you were injured on the job or developed a medical condition because of your work—such as a cumulative trauma like a repetitive strain injury (RSI) or lung disease from exposure to toxic chemicals—you’re no doubt hoping to be eligible for workers’ compensation benefits. But what can you do if your claim has been denied? The answer could depend on the reasons for the denial.
Common Reasons for Denial of Workers' Comp Claims
Employers or their insurance companies sometimes look for any possible reason to deny workers’ comp claims. Of course, that reason should be a valid one under the law. There are several common reasons for claim denials, including:
- Missed deadlines. In order to receive workers’ comp benefits, you must report your injury or illness to your employer right away. After that, you generally have to file a workers’ comp claim with the state agency (although in some states, your employer or the insurance company will take care of this step after you’ve notified them of the injury). States have different time limits for reporting injuries and filing claims. If you miss the deadlines, your claim will probably be denied. In some states, you won’t be penalized for missing the reporting deadline (by not giving your employer write a notice of the injury), as long as your boss actually knew that it happened. Still, your claim has to be filed in time.
- Disputes about whether the injury is work-related. Your employer may say that you weren’t working when you were injured, that you were involved in some kind of misconduct at the time, or that your current medical condition isn’t actually a result of a workplace accident or exposure. Whatever the reason for the dispute over whether your injury or illness is work-related, you’ll need to gather evidence to support your claim. Maybe you need witness accounts about the circumstances of the accident. Or you may need more medical evidence. If your treating doctor has already attributed your condition to your work, but the insurance company disagrees, you may need to attend an independent medical examination to get another doctor’s opinion.
- Your condition doesn’t meet state guidelines. The law in your state may have special restrictions on workers’ comp claims for cumulative trauma or psychological conditions. Some states rule out workers’ comp benefits for illnesses caused by long-term emotional stress at work. Or your injuries might not be severe enough to meet the requirements for a workers’ comp claim.
- You filed the claim after you left your job. Insurers usually deny claims that were filed after the employee was fired, laid off, or quit. But you might have had a good reason for the delay. Maybe you reported the injury while you were still at the job, or you were injured in the period after you gave (or were given) notice but before your last day. Or maybe you were fired in retaliation for reporting a workplace injury (which is illegal). Some states have special rules for workers’ comp claims filed after you left your job. If you qualify for one of the exceptions in your state's law, you may be able to contest the denial.
What to Do When Your Workers' Comp Claim Is Denied
Don’t give up your right to workers’ comp benefits just because your claim was initially denied. First, look closely at the letter telling you that your claim was denied. It will probably include the reasons for the denial. If you think it was simply a matter of mistaken paperwork or something similar, you might consider contacting the claims adjuster to see if you can clear up the problem. But this route isn’t likely to be successful unless your employer or the insurance company made a bona fide mistake and admits it. More likely, you’ll have to consider appealing the denial.
Appealing a Workers' Comp Claim Denial
The letter you received may include information about how to appeal the denial of your claim. If so, read it carefully. The appeals process varies in each state. Often, the first level of appeal will be at a hearing before an administrative law judge, where you’ll have to present medical and other evidence to support your claim. The hearing can be through a state labor department or a state board of workers’ compensation. There are additional levels of appeal beyond the initial administrative levels as well, which vary depending on the state.
When You Need a Lawyer
Unless your claim was denied due to a simple mistake that was immediately cleared up, it would be smart to speak with a workers' comp lawyer as soon as possible. An attorney can help you determine whether an appeal would be the best course of action for you. The timelines for workers’ comp appeals are short and strict, and you don’t want to lose your rights to benefits just because you missed a deadline.
Before you consider filing an appeal yourself, you should definitely talk to an attorney. Appeals are complicated legal processes, involving rules of evidence and civil procedure that the judge will expect you to know. If you don’t win at the initial levels, you may not be able to present additional evidence later in the process. One of the reasons that many injured employees lose their appeals is because they didn’t have an experienced workers’ compensation attorney at their side to help them prepare a strong case. Also, most workers' comp lawyers charge only a percentage of the benefits you actually receive, so it won't cost you anything unless you win.