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Workers' Compensation Claim Denials & Legal Options | Workers' Compensation Law Center | Justia
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Onward Blog</a></li> </ul> </div> </div> </li> </ul> </div> </div> </header> <div id="main-content" class="main-content font-opensans has-topnav-padding"> <nav class="breadcrumbs small-font font-helvetica"> <a href="/">Justia</a> <span class="breadcrumb-separator"></span> <a href="/workers-compensation/">Workers’ Compensation Law Center </a> <span class="breadcrumb-separator"></span> Workers' Compensation Claim Denials & Legal Options </nav> <div class="primary-content-wrapper"> <div class="primary-content"> <div class="wrapper has-padding-content-block-x2large has-no-top-padding blocks clearfix"> <div class="title-wrapper"> <h1 class="heading-1 has-margin-top-10">Workers' Compensation Claim Denials & Legal Options </h1> </div> <div class="content-links -semibold content-headings -large-gap"> <div class="set-maxlimit -max-landscape-tablet to-large-font"> <p> You should not lose hope if your employer or its workers’ compensation insurer denies your initial claim for benefits after an accident or illness on the job. Unfortunately, many deserving claimants need to go through the appeals process to get the benefits to which they are entitled. You should review the letter that notifies you of the denial, which will describe the basis for the denial. Sometimes the problem can be easily fixed. For example, you might have forgotten to submit required documentation, or the insurer might have made a mistake. You might be able to address the error with the adjuster for the insurer. If the situation involves more than a minor mistake, though, you probably will need to file an appeal. </p> <h2 class="heading-3"> Possible Reasons for Denial </h2> <p> Like any other insurer, workers’ compensation insurers are profit-based companies driven by their bottom lines. This gives them an incentive to deny a claim whenever possible. Insurers deny many claims on the basis that a worker’s injury was not related to their job, as is required to receive workers’ compensation benefits. This might involve arguing that a pre-existing condition caused your injury or that you were not actually working at the time of an accident. To bolster your position in an appeal, you may want to gather further medical documentation about your condition. This could include an independent medical examination if your insurer does not accept the opinion of your treating doctor. You also may want to introduce testimony from witnesses who saw the accident. They could confirm that you were performing your job duties and were not engaging in misconduct. </p> <div class="block -boxed -with-icon to-normal-font "> <header class="block-header bg-justia-blue"> <svg class="jicon -large -fill-white" role="img" title="Information" alt="Information" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/round-simple-icons-sprite.svg#information"></use> </svg> <span class="heading-3 has-no-margin color-white">Common Reasons for Denial</span> </header> <div class="block-wrapper has-no-top-margin"> <ul class="list-no-styles has-no-left-padding list-with-icons -small-gaps list-gutter--normal "> <li class="line-height-1-5"> <svg class="jicon -tiny -fill-bright-blue" role="img" title="Right" alt="Right" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/simple-icons-sprite.svg#right"></use> </svg> <span class="text">The injury was not related to the worker’s job</span> </li> <li class="line-height-1-5"> <svg class="jicon -tiny -fill-bright-blue" role="img" title="Right" alt="Right" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/simple-icons-sprite.svg#right"></use> </svg> <span class="text">The injury or claim was not timely reported or filed</span> </li> <li class="line-height-1-5"> <svg class="jicon -tiny -fill-bright-blue" role="img" title="Right" alt="Right" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/simple-icons-sprite.svg#right"></use> </svg> <span class="text">The right to benefits is restricted because the claim involves a mental or emotional condition</span> </li> <li class="line-height-1-5"> <svg class="jicon -tiny -fill-bright-blue" role="img" title="Right" alt="Right" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/simple-icons-sprite.svg#right"></use> </svg> <span class="text">The condition is not as severe as claimed</span> </li> </ul> </div> </div> <p> Other denials may arise from procedural problems. The insurer may argue that you did not report your injury to your employer or file your workers’ compensation claim within the required deadlines. There are very few exceptions for missing these deadlines. If your employer actually knew about the injury or illness, however, your claim may survive a failure to formally report the injury. </p> <p> Complex conditions may pose more difficulties in receiving benefits. If you are suffering from a mental illness caused by your job, or if your condition resulted from emotional stress, your right to benefits may be restricted. The insurer also might argue that your condition is not as severe as you are claiming, especially if it is not visible or medically straightforward. </p> <h2 class="heading-3"> Filing a Claim After Leaving Your Job </h2> <p> The general rule is that you cannot bring a claim for workers’ compensation benefits after leaving your job. This is true regardless of whether the employee or the employer ended the relationship. However, you cannot be fired because you reported an injury to your employer. You may have a right to benefits following a <a href="/employment/retaliation/">retaliatory termination</a>. Many states also provide exceptions for an injury that the employee reported before they left the job or for an injury that the employee suffered while they were still at the job but after they gave or received notice of their departure. </p> <h2 class="heading-3"> Appealing a Denial </h2> <p> Each state provides its own set of procedures for appealing a denial of a workers’ compensation claim. You may need to start by pursuing an appeal through the administrative process, which may involve a hearing before the state board of workers’ compensation. Ultimately, you may be able to take your claim to state court. You will need to take action within a short period to preserve your right to an appeal. </p> <p> While you may not need an attorney to file your initial claim, you probably would benefit from retaining an attorney to help you contest a denial. The attorney can help you collect many forms of evidence and present them in a persuasive manner. Mistakes made early in the appeals process can permanently damage your case at later stages of review. An attorney can help you avoid these missteps through their superior knowledge of the system. </p> <div class="block -boxed -with-icon to-normal-font "> <header class="block-header bg-justia-blue"> <svg class="jicon -large -fill-white" role="img" title="Information" alt="Information" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/round-simple-icons-sprite.svg#information"></use> </svg> <span class="heading-3 has-no-margin color-white">Explore the Justia Lawyer Directory</span> </header> <div class="block-wrapper has-no-top-margin"> <p class="text">Justia offers a <a href="https://www.justia.com/lawyers" target="_blank">lawyer directory</a> to simplify researching, comparing, and contacting attorneys who fit your legal needs.</p> </div> </div> <p class="color-dove-gray"> <time datetime="2024-10-18" pubdate> <em> Last reviewed October 2024 </em> </time> </p> </div> <div class="-show-desktop"> <p data-directive="j-expand" class="heading-3 expand-v2 cursor-pointer -display-block -expanded" data-collapsed_class="hidden" data-expanded_class="-expanded" data-section="mobile-navigation-list"> Workers’ Compensation Law Center Contents <span> <svg class="down-arrow -fill-blue jicon -medium" role="img" title="Mobile Navigation" viewBox="0 0 270 270"> <use xmlns:xlink="http://www.w3.org/1999/xlink" href="/justatic/shared/images/icons/simple-icons-sprite.svg#down"></use> </svg> </span> </p> <div id="mobile-navigation-list" class="-collapsed -expanded"> <ul class="list-no-styles has-no-left-padding has-no-bottom-margin"> <li> <a href="/workers-compensation/">Workers’ Compensation Law Center </a> <ul class=""> </ul> </li> <li> <a href="/workers-compensation/filing-a-workers-compensation-claim/">Filing a Workers’ Compensation Claim & the Legal Process </a> </li> <li> <a href="/workers-compensation/reporting-a-work-injury/">Reporting a Work Injury Under Workers’ Compensation Law </a> </li> <li> <a href="#" class="color-black">Workers' Compensation Claim Denials & Legal Options </a> <ul class=""> </ul> </li> <li> <a href="/workers-compensation/time-limits-in-workers-compensation-claims/">Time Limits & Deadlines Under Workers’ Compensation Law </a> </li> <li> <a href="/workers-compensation/independent-medical-examinations/">Independent Medical Examinations in Workers' Compensation Claims</a> </li> <li> <a href="/workers-compensation/workers-compensation-settlements/">Workers’ Compensation Settlements</a> </li> <li> <a href="/workers-compensation/depositions-in-workers-compensation-claims/">Depositions in Workers’ Compensation Claims & the Legal Process </a> </li> <li> <a href="/workers-compensation/federal-workers-compensation/">Federal Workers’ Compensation Law </a> </li> <li> <a href="/workers-compensation/eligibility-for-benefits/">Eligibility for Workers' Compensation Benefits</a> </li> <li> <a href="/workers-compensation/special-types-of-injuries-and-illnesses/">Complex Types of Injuries and Illnesses at Work & Legal Implications </a> </li> <li> <a href="/workers-compensation/getting-medical-treatment/">Getting Medical Treatment for a Work Injury or Illness & Legal Considerations for Workers </a> </li> <li> <a href="/workers-compensation/working-with-a-workers-compensation-lawyer/">Working With a Workers’ Compensation Lawyer </a> </li> <li> <a href="/workers-compensation/insurance-company-penalties/">Insurance Company Penalties Under Workers' Compensation Law </a> </li> <li> <a href="/workers-compensation/third-party-claims-based-on-work-injuries/">Third-Party Legal Claims Based on Work Injuries </a> </li> <li> <a href="/workers-compensation/reopening-a-workers-compensation-claim/">Reopening a Workers’ Compensation Claim & the Legal Process </a> </li> <li> <a href="/workers-compensation/employers-without-workers-compensation/">Employers Without Workers’ Compensation & Employees' Legal Options </a> </li> <li> <a 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