Suppose your worker’s compensation claim gets denied. In that case, you may hire a workers comp attorney to help file an appeal to reestablish your benefits, as they understand workers’ compensation laws. They will help negotiate with the insurance adjusters to get a fair settlement after completing your medical treatment.

Suppose you’ve suffered a work-related injury or developed a job-related medical condition, like a repetitive strain injury or an illness from workplace exposure. You likely expect to qualify for workers’ compensation benefits in that case. However, after filing workers compensation claim, it gets denied, and your next steps hinge on the reasons behind the rejection.

Top Reasons Why Workers’ Comp Claims Are Denied

Employers and their insurance companies often seek grounds to deny workers’ compensation claims, subject to the legal validity of their reasons. Common factors leading to claim denials encompass:

  • Incomplete and late paperwork: The insurance company may deny the claim if your application form and paperwork are incomplete or inaccurate. In other cases, the claim may also get denied if the employer files paperwork late. Therefore, it is vital to comply with the deadlines to approve the worker’s comp claim.
  • The injury occurred when the worker was on lunch break: Suppose the injury happened when the worker was on lunch break; the claim will be denied automatically. However, a worker’s compensation claim attorney may help when considering many factors. 
  • You were under the influence: If the worker was under the influence of drugs or alcohol while at work and then got injured, the claim will automatically be denied. Many employers demand an immediate drug test after a workplace injury.
  • You didn’t receive medical care from an authorized healthcare provider: It may happen that the worker seeks treatment from a healthcare provider who is not authorized by the specific healthcare provider. In such cases, payment for the treatment will not be covered in the claim and will be denied. However, there is an exception to this in case of emergency medical care and the injuries are severe.
  • Your injury was caused by horseplay: In some situations, coworkers may goof up at work, and if you get hurt, the insurance company and the employer may deny the claim. The insurance company may be of the opinion that the worker was not performing the job duties when you got hurt.
  • Your employer disputes the accident or injury: Sometimes, the worker and the employer may dispute the actual incident at the workplace. The employer may deny that the injury did not happen at the workplace. In such cases, the insurance company may deny the claim. Therefore, it is necessary that the employer agree with the statement for you to get a compensation claim.
  • Your injury is connected to a pre-existing condition: If you are struggling with a pre-existing condition and you are filing a new injury claim for a similar injury, you can be denied by the insurance company. The insurer will fight and ensure you do not receive any worker settlement claim because your condition was pre-existing and not due to work.

How Do You Appeal a Workers’ Comp Claim Denial?

The appeal process is your next avenue when faced with a denied workers’ comp claim. Typically, this involves these steps:

  • Understand the Denial: Carefully review the denial letter to understand its reasons. Knowing the specifics is crucial for your appeal.
  • Contact the Insurance Claims Adjuster: If there seems to be a misunderstanding or paperwork issue, communicate with the adjuster. However, this may not work if the denial is based on substantial grounds.
  • Gather Evidence: Collect all relevant evidence supporting your claim. This might include medical records, witness statements, or any documentation proving your injury’s work-related nature.
  • Consult with an Attorney: Seeking legal advice is wise. An experienced workers’ comp attorney must be hired to guide you through the process and ensure you cover all necessary aspects. 
  • File an Appeal: Submit an appeal to your state’s workers’ comp board or commission. This involves completing specific forms and providing the gathered evidence.
  • Attend a Hearing: Be prepared for a hearing where you present your case. Having legal representation can significantly bolster your chances.

Remember, the appeal process varies by state, so following your state’s specific procedures is essential.

Deadlines For Filing Your Workers’ Comp Appeal

Adhering to deadlines is critical when appealing a denied workers’ comp claim. The exact timelines can vary by state, but generally, you must file an appeal within a specified period after the denial. This period often ranges from 30 to 90 days. 

Missing these deadlines could jeopardize your ability to challenge the denial, so acting promptly and staying informed about your state’s specific timelines is crucial. Seeking legal guidance can ensure you meet these deadlines and navigate the appeals process effectively.

Want To File An Appeal? Contact a Worker’s compensation lawyer

Seeking guidance from a workers’ comp attorney is crucial when considering an appeal. The appeals process, which involves legal nuances and strict timelines, demands expertise. 

They can assess the merits of your case, guide you through the complex legal procedures, and help prepare a robust appeal. Missing deadlines or navigating the legal complexities without proper representation may jeopardize your chance to secure benefits.