​What Happens When Your Workers’ Compensation Claim Gets Denied?

What Happens If My Workers Compensation Claim is Denied?

You are at work, and an injury has happened. After getting hurt at your workplace, you follow every procedure to receive your workers’ compensation benefits. You contacted human resources, went to the medical examinations, and submitted yourself to seemingly endless questions, but you received a denial of your workers’ compensation claim and benefits. You might feel overwhelmed and confused, with concerns over how you will cover the costs of your injuries without benefits.

You likely have many questions. Why did this denial happen? What should I do now?

The best thing to do in this situation is to consult an experienced workers’ compensation attorney. They can review the denial reasons and advise on the best path to appeal and receive benefits.

Read on to learn more about what happens after a denied workers’ compensation claim.

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What is Workers’ Compensation?

Employers must carry workers’ compensation insurance to protect employees from workplace injuries. Workers’ compensation provides medical benefits to the employee during their employment in exchange for mandatory relinquishment of the employee’s legal right to sue the employer for negligence. Workers’ compensation laws aim to provide benefits and mitigate the financial burden of lost wages and new medical bills created by workplace injuries.

Which Employers Must Carry Workers’ Compensation Insurance?

In most states, employers with more than a certain number of employees must carry workers’ compensation insurance. The requirement and minimum amount of coverage vary depending on the state. For example, some states require any employer with five or more employees to carry workers’ compensation insurance.

Who Can Seek Coverage Under Workers’ Compensation Insurance?

Workers’ compensation insurance covers only employees. An employee works in the service of another person or business under any contract for hire. Employers may periodically hire temporary employees to perform services like independent contractors, volunteers, or freelancers. These workers are not employees and do not have workers’ compensation insurance coverage.

How Does My Disability Status Affect My Access to Workers’ Compensation Benefits?

When you initially apply for workers’ compensation benefits, the insurance company will assign you a disability status. They might categorize you as either totally disabled or partially disabled. If they state you are disabled, after 104 weeks, the insurer can require a medical examination.

If, after the test, you are at least 35 percent disabled, it is a total disability. If, after 500 weeks, you are less than 35 percent disabled, you will have a partial disability for workers’ compensation purposes.

What Benefits are Covered By Workers’ Compensation Benefits?

The purpose of workers’ compensation is to cover the medical needs and other benefits an employee requires after getting hurt at work. Examples of benefits covered by workers’ compensation insurance include:

Vocational rehabilitation

For employees eligible for vocational rehabilitation, your employer’s workers’ compensation policy should cover the costs of the service.

Wage replacement benefits

If your injury causes you to lose time at work or you can only return to light duty, your employer’s insurance provider must pay for your lost income or lost earning capacity.

Medical treatment

Workers’ compensation benefits cover an employee’s required medical treatment. Treatment may include surgery, physical therapy, hospital stays, rehabilitation costs, or other treatment related to the injury covered by your employer’s workers’ compensation insurance policy.

Death benefits

If a workplace injury causes the death of an employee, certain surviving family members can recover death benefits from the workers’ compensation system.

What Happens During the Workers’ Compensation Appellate Process?

You have already suffered an injury. Now, to add insult to injury, your claim was denied. The good news is this is not the end; you have options. If an insurer denies an injured worker’s claim, the worker has the legal right to appeal or reopen their case. The appeal process can be grueling. An experienced workers’ compensation attorney can be your best resource during a workers’ compensation appeal.

Speak To Your Employer

After an initial claim denial, you should speak to your employer. A simple conversation may resolve the issue. Denials might be due to a misunderstanding or a clerical error. You can avoid an appeal entirely by speaking to your employer or insurer. Better yet, have your attorney speak with them.

The Denial Letter

If your claim is not approved, you will receive a denial letter. This letter is essential, so read it carefully and note everything explained. Your denial letter will contain the reason the insurer denied your claim and the deadline for appeal. If you fail to meet the deadline for appeal, you may lose your right to appeal and receive workers’ compensation benefits.

Appellate Process

If your case gets denied, then your case will proceed to appellate review. The procedures for appeals vary from state to state.

At the federal level, The Employees’ Compensation Appeals Board (ECAB) reviews the initial decision from the Office of Workers’ Compensation Programs. After the Office of Workers’ Compensation Programs (OWCP) makes a final decision, you can file an appeal with the Board.

The ECAB reviews the decision from the OWCP. Workers cannot submit new evidence on appeal. Each appeal is reviewed by a panel of judges considering the record and every argument the employee or attorney raises. Once they reach a decision, the judges’ panel must issue a written decision explaining why they denied the appeal or issued an order overruling the original decision.

Employees must file an appeal with the OWCP within 180 days after their initial denial. The review from the ECAB is the final decision. There is no further remedy for an employee seeking an appeal.

The Board may grant each side an oral argument to present their cases in front of the judges’ panel. Oral arguments are at the sole discretion of the Board.

The appeals process is unique in each state. If you have suffered an injury on the job and received a denial of benefits, contact a workers’ compensation attorney in your area immediately.

What Do I Need to File an Appeal?

If you need to file an appeal with the Office of Workers’ Compensation Programs, there are some documents that you will need to appropriately file your appeal, including:

  • A timesheet that shows you were working at the time you suffered an injury
  • A copy of your medical records
  • A second medical examination/ a second medical opinion

What Must I Prove to Win a Workers’ Compensation Appeal?

An employee should be ready to present a case for their workers’ compensation appeal. You must prove that your injury happened on the worksite or during your working hours and that your workplace injury caused your disability, and now you need medical care.

You must prove causation to win a workers’ compensation claim or an appeal. Causation is the most challenging part of a claim to prove. Employees must show that their injury happened in the course of their employment, which is easier in some cases than others.

It is often difficult for employees to prove claims on their own. Attorneys with experience in workers’ compensation law know they need to connect the facts of your claim to your work and have experience doing just that.

When Should I Appeal a Workers’ Compensation Benefit Denial?

When to file a workers’ compensation appeal is a strategic decision.

A lawyer can file a worker’s compensation claim appeal if:

  • If you have evidence, the insurer denied your claim because of an irregularity, fraud, or clerical error. You can file a complaint with the state’s workers’ compensation administrative office.
  • You should file an appeal if you were denied and do not entirely understand the terms listed in your denial letter. If, after filing an appeal, you still do not understand the reason for denial, you should contact a workers’ compensation attorney in your area.

Why Do Some Workers’ Compensation Claims Get Denied?

Unfortunately, not every worker collects on their workers’ compensation claim. There may be several reasons that an employee does not receive the benefits they may deserve after an injury.

Workers’ compensation is a form of insurance. Your employer’s insurance provider will work to avoid paying out any claims to protect the insurance company’s profit margin. In worker’s compensation cases, insurance companies will try to use technicalities to avoid paying you, like missed deadlines or failing to complete a specific form.

The most common reasons insurance companies deny workers’ compensation claims include:

  • The employee was laid off or fired.
  • The employee’s physical condition does not qualify under the employer’s workers’ compensation insurance policy.
  • The employee is exaggerating their injuries, but their injuries are not severe enough to warrant workers’ compensation coverage.
  • The employee was intoxicated at the time the injury happened.
  • The employer files a dispute to the employee’s claim.
  • The employee missed an application deadline.
  • The employee is hurt, but the injury did not happen during work hours.
  • The employee did not notify the employer of the accident and the injury.
  • The employee had a preexisting condition that is the underlying cause of the injury or contributes to making the injury worse.
  • The employee did not seek medical treatment after an injury.
  • The employer did not make a report to their insurance company.

Can I Reopen My Workers’ Compensation Claim?

Reopening a workers’ compensation claim is different from an appeal. There are some circumstances where reopening a case is the more appropriate option.

You may consider reopening your workers’ compensation case if any of these circumstances apply:

  • Your employer has evidence of fraud or a clerical error that resulted in an unjust denial of benefits.
  • The employer does not have any lighter job duties available for the employee.
  • Your injury has progressed or returned.
  • There is evidence that the settlement was unfair or insufficient.

How Can a Workers’ Compensation Attorney Help Me?

A workers’ compensation attorney can help you build your case for benefits. An attorney can help you protect your legal rights even if insurance companies or employers try to deny your legitimate claim.

Many claims receive a denial because of a technical error. Many technical errors are simply due to missed or incomplete paperwork. Having an attorney working on your behalf eliminates the risk of missing out on your benefits because of missing a deadline or submitting incomplete paperwork.

A workers’ compensation attorney can help you negotiate with your employer’s insurance provider. Your attorney can help you understand your claim’s value, manage your compensation expectations, and pursue the financial recovery you need after a workplace injury. With your attorney’s help, you can reach your goal of financial recovery from an injury.

You may need to proceed to a hearing if you cannot reach a fair settlement offer from your employer’s insurance company. Your attorney can help you prepare for how the case will progress and what you should expect at the hearing.

Finally, your attorney will represent you at the hearing or trial of your workers’ compensation claim. It may be intimidating to stand in front of judges telling your story and making your case on your own. A workers’ compensation attorney can take that burden off you and help you tell your story effectively and persuasively.

Contact a Workers’ Compensation Attorney In Your Area Today

Tatiana Boohoff, Lawyer for Workers' Compensation Cases near Tampa. 
Tatiana Boohoff, Workers’ Compensation Attorney in Tampa. 

You need a solid legal team in your corner as you try to get the compensation you deserve after a workplace injury. You have already suffered an injury and fought through an initial claims process, and now you have received a denial. Many people feel hopeless in this situation, but there are additional options to fight for your benefits.

With the right legal team working for you, you can put yourself in the best position to maximize your compensation after suffering an injury while on the job. If you received a denial of your workers’ compensation benefits, contact an attorney in your area immediately.

If you recently suffered an injury and need help filing your initial claim, a Workers’ Compensation lawyer can help with this process, as well. Never hesitate to seek assistance with an initial claim or if you need to appeal a benefits denial.

Request A Free Consultation Today!


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March 6, 2023
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