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How to Appeal a Workers' Compensation Denied Claim
The workers' compensation system was designed to provide certain benefits to workers injured in the course and scope of their employment without having to prove negligence fault by their employers or coworkers. When workers are denied these benefits, they can appeal the denied claims.
Reasons for Denial
Benefits are denied for a wide variety of reasons. These are some common reasons why your workers' compensation claim may have been denied:
- Your injury did not occur while performing your job.
- Your injury was caused by a preexisting injury or condition.
- Dispute as to when or where the injury occurred.
- A health provider concluded you were not disabled as a result of your work injury.
- Dispute whether you sustained injuries at all.
Steps to Appeal the Decision
Methods of appealing the denial of your workers' compensation claim vary among the states unless you are a federal employee. But there are a few things everyone can do when seeking review of a denied claim:
- Contact the insurer to learn why your benefits were denied. It may be as simple as failing to provide a specific document.
- Ask the insurer if it will reconsider its decision.
- File a formal appeal within the stated timelines to the appropriate administrative agency.
- Hire a workers' compensation attorney to handle the appeals process.
What Your Attorney Can Do
Your workers' compensation attorney is paid based on a small percentage of the benefits you receive from your claim, so attorney fees are not a consideration. Your lawyer will determine the reasons for the denial of your claim and begin to gather documentary evidence, contact possible witnesses to your injury, and retain experts from the medical field and your industry if necessary.
Many claims are denied based on medical issues. Your attorney may have your injury or disability evaluated by an independent medical specialist or will review your case with your present health care provider to determine if a more detailed medical report should be drafted. Your worker's compensation lawyer will also determine if additional proof is needed to demonstrate a disability or directly related injury.
Some states have review boards that review your claim; in others the appeal is heard before an administrative law judge (ALJ). These hearings are similar to court trials, but without juries, and the rules allowing certain evidence may be different. Witnesses may be heard and other documents introduced as evidence for the ALJ or board to consider.
If the review is denied, the next step is an appeal to the Workers' Compensation Court of Appeals or other appeals board, depending on your state. At this level of review, only the record of the hearing is considered—no new evidence may be introduced and there is no hearing. The court considers only the ruling by the ALJ or review board and affirms, modifies, reverses, or remands the case for further proceedings or findings.
Should the ruling be adverse to you, the next step is an appeal to your state’s court of appeals.