Receiving a denial of your workers’ compensation claim can be frustrating and disheartening. After all, you’re hurt, your medical bills are piling up, and you may be unable to work for an extended period of time. Unfortunately, this is an all-too-common scenario for injured workers. In a recent survey, we found that 27% of workers' comp claims were initially denied.
The good news, however, is that you have the right to appeal the decision. In this article, we explain the appeals process and provide tips on how to challenge your workers’ comp denial.
Contact the Insurance Company
The insurance company for your employer will typically make the initial decision on your workers’ compensation claim. If you receive a denial, your first step should be to contact the insurance company to find out why your claim was denied. Sometimes a claim is denied because the paperwork wasn’t filled out correctly or an important document was missing. The insurance company may allow you to fix these types of technical mistakes and reconsider your claim.
Other claims are denied because the insurance company believes you have not met the eligibility requirements for receiving benefits. For example, the insurance company may deny your claim because your injury happened away from the workplace or during non-working hours. Or, the insurance company may believe that you had a preexisting condition that was the real cause of your injuries (such as a prior sports injury). (Read our article on common reasons for workers' comp denials for other justifications the insurance company may use to deny you benefits.)
Whatever the case, you can usually ask the insurance company to reconsider its decision. This can be worthwhile if you have additional facts or documents for the insurance company to consider (for example, medical records showing that your sports injury required minimal treatment).
File the Appeal
If you can’t work things out with the insurance company, you will typically need to file a formal claim or appeal. The notice of denial from the insurance company will usually lay out the procedures you must follow to file an appeal. It's important to keep in mind that there are strict deadlines for appealing workers’ comp denials, which vary from state to state. In many states, workers have one or more years to appeal a workers’ comp claim denial. For example, in California, a worker has one year to file if the insurance company ignored or denied the claim, and five years to file if the insurance company paid any benefits on the claim. However, in other states, the timeline may be as short as a few weeks or months. For example, in Ohio, a worker has only 14 days to appeal after receiving a claim denial.
It’s also important to file your appeal according to the procedures of your state. For example, in some states, your appeal may be as simple as sending a letter to your state’s workers’ compensation agency. In other states, you may need to fill out certain forms, attach certain documents, or send multiple copies of your appeal. If you fail to follow the rules, you may be denied benefits, even if you would have otherwise been entitled to them. (For more information on the appeal procedures in your state, see State-Specific Information for Workers’ Compensation.)
In many states, you may have the option (or may be required) to participate in mediation before your hearing takes place. For instance, Pennsylvania and North Carolina both require you to go to mediation before you attend a formal hearing.
At mediation, you and the insurance company will each get a chance to present your cases to a mediator—a neutral third party who tries to help you resolve the dispute. This usually happens through informal conversations in a conference room. Unlike a hearing, a mediation does not require formal arguments or follow procedural rules. However, it can be very helpful to have an attorney representing you at this stage. A lawyer can help you figure out what arguments are the most persuasive and help you evaluate settlement offers from the insurance company.
If you and the insurance company come to an agreement at mediation, you will not need to continue with your appeal. The agreement will be formalized in writing and likely reviewed by a workers’ comp judge. If you cannot agree to a settlement, however, you will continue on to the next step.
In most states, the next step is a workers’ compensation hearing. Although a workers’ comp hearing is less formal than a trial, it does have some similarities. For example, the parties make legal arguments, present evidence, and elicit testimony from witnesses. There are also certain procedural rules that must be followed, and a workers’ comp judge (or other official) will preside over the hearing.
To succeed at the hearing, you will need to convince the workers’ comp judge that the initial denial was wrong. The evidence you should present will depend on your particular case and the reason for the denial. For example, if your appeal was denied because the insurance company believes you were not seriously injured, you should present reports from your doctors showing the severity of your injuries. If your appeal was denied because the insurance company believes you weren’t working at the time of your injury, you might present time cards or a statement from a coworker who witnessed the injury.
Although you have the right to represent yourself at the hearing, it’s highly recommended that you have an attorney at this stage. A qualified workers’ comp attorney will be able to craft persuasive legal arguments, present relevant evidence, follow procedural rules, and present your case in the best light possible. You’ll also be on equal footing with the insurance company, as it will likely have an attorney as well.
If you’re unsuccessful at your hearing, many states allow you to file a second administrative appeal. The workers’ compensation appeals board, or a select panel of workers’ comp judges, will usually handle this appeal. In most cases, this is not an opportunity to present your evidence for a second time. Instead, this is your chance to explain why the original hearing officer’s decision was wrong, based on the evidence presented at the hearing.
If you don’t win your second appeal, the final step in most states is to appeal through the state court system. Essentially, you will need to file a lawsuit against the insurance company or the state workers’ compensation board (depending on your state’s procedures). In many states, your case will proceed in court like any other lawsuit and will eventually be decided by a judge or a jury. During the process, you will have to follow all of the rules of procedure and evidence in your state, which can be quite complicated. If you haven’t already, you should consult with a lawyer before filing an appeal through state court.