What to Do If Your Workers' Compensation Claim Is Denied

This page has been written, edited, and reviewed by a team of legal writers following our comprehensive editorial guidelines. This page was approved by Founding Partner,  LaRuby May who has years of legal experience as a personal injury attorney. Our last modified date shows when this page was last reviewed.

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 | January 20, 2025
What to do if your workers compensation claim is denied

Facing a workers comp claim denial can be stressful and frustrating. It might feel like a dead end, but it’s not. Many denials happen due to errors or lack of evidence, and these issues can often be fixed.

May Jung Law Personal Injury Lawyers help injured workers challenge denied claims and fight for the workers compensation benefits they deserve. Our team understands the system and knows how to handle the insurance company or claims administrator. If your claim was denied, we’re here to guide you through the appeals process and secure the compensation you’re entitled to.

Common Reasons for Workers' Compensation Claim Denials

A workers' comp claim denial can happen for several reasons. Understanding these common causes can help you avoid mistakes and prepare a stronger case. Some of the typical reasons claims are denied include:

Late Reporting

Timely reporting is essential in a workers' comp case. If you delay informing your employer about your work-related injury, the claims administrator or insurance company may deny your claim.

Late reporting often raises doubts about when and how the injury happened. Most states have specific deadlines for reporting workplace injuries, which can range from a few days to weeks. Failing to meet these deadlines could lead to a denied claim.

To avoid this, always report your injury immediately. Provide clear details about what occurred and when. Acting quickly ensures your employer and the insurance carrier have accurate information to process your claim.

Disputes Over Injury Origin

One of the most common reasons for a workers' comp claim denial is a dispute about how or where the injury happened. The insurance company or claims administrator may argue that your injury was not work-related or was caused by pre-existing conditions.

To strengthen your case, it’s crucial to have solid evidence. This includes medical records, witness statements, and documentation that clearly link your injury to your job duties. For example, if the injury occurred on-site while performing work-related tasks, ensure all details are documented.

An experienced attorney can help gather and present this evidence. They can challenge the insurance company’s claims and prove that your work-related injury deserves coverage under workers compensation.

Insufficient Medical Evidence

A lack of proper medical records is another common reason for a denied claim. The insurance company may argue that your injury isn’t severe enough to require medical treatment, or they may claim there’s no proof the injury is work-related.

To avoid this, always seek medical care immediately after a workplace injury. Ensure that your doctor provides detailed documentation about the nature of your injury, how it occurred, and the treatment required. These records are critical for supporting your workers' comp claim.

If your claim was denied due to insufficient evidence, an experienced attorney can help gather additional documentation, such as second medical opinions or specialist reports. This ensures your case is backed by strong, undeniable proof of your work-related injury.

Administrative Errors

Mistakes in paperwork are a common but avoidable reason for a workers' comp claim denial. Even small errors, like missing information or incorrect details, can lead to a rejection by the claims administrator or insurance company.

For example, failing to include the date when the injury happened or omitting key medical records can raise questions about your claim's accuracy. These errors may delay the process or result in a denied claim altogether.

To prevent this, carefully review all forms before submission. Ensure that everything is complete, accurate, and submitted on time. Keeping copies of all paperwork is also essential. Working with a workers' compensation lawyer ensures your documents are error-free and meet the requirements of the workers' compensation board.

Immediate Steps to Take Following a Claim Denial

Immediate steps to take following a claim denial

If your workers' comp claim is denied, there are immediate steps you can take to protect your rights and address the situation. Acting quickly and following these steps can increase your chances of successfully appealing the decision.

Review the Denial Letter

The denial letter from the insurance company or claims administrator will outline the reasons your claim was rejected. It’s important to review this letter carefully to understand the specific issues.

Pay close attention to any errors, missing evidence, or questions raised about how your injury happened. The letter should also provide information about deadlines and steps for filing an appeal.

If you’re unsure how to interpret the letter, consulting an experienced attorney can help. They can review the denial, explain your options, and create a plan to challenge the decision. Taking this first step ensures you are well-prepared to move forward.

Consult with a Workers' Compensation Attorney

After a workers' comp claim denial, consulting an experienced attorney is one of the most important steps you can take. An expert lawyer specializing in workers compensation cases can review your case, identify mistakes, and help you build a strong appeal.

They will handle communication with the insurance company or claims administrator, ensuring your rights are protected. A lawyer can also gather additional evidence, such as updated medical records or expert opinions, to address the reasons for the denial.

Most workers' compensation lawyers work on a contingency basis, meaning you don’t pay unless they win your case. Their expertise significantly increases your chances of overturning a denied claim and securing the workers' compensation benefits you deserve. Acting quickly to consult a lawyer ensures you stay within appeal deadlines and have the best chance of success.

What Is the Appeals Process

What is the appeals process

If your workers' comp claim is denied, you have the right to appeal the decision. The appeals process provides a chance to challenge the denial and present evidence to support your case. Each state has specific rules and timelines for filing an appeal, so it’s important to act quickly.

Some main steps involved in the appeals process, which include filing an appeal, exploring alternative resolutions, and attending formal hearings include:

Filing an Appeal

The first step in the appeals process is submitting a formal appeal to the workers' compensation board. This involves completing the necessary forms, providing documentation, and meeting the deadlines stated in your denial letter.

During this step, you’ll need to present evidence, such as medical records or witness statements, to counter the reasons for the denial. An experienced attorney can ensure your appeal is properly filed and includes all necessary information to strengthen your case.

Alternative Dispute Resolution

After filing an appeal, you may be offered Alternative Dispute Resolution (ADR). This process helps solve disagreements without going to court. It includes methods like mediation or settlement conferences.

In mediation, a neutral third person helps you and the insurance company reach an agreement. This can save time and stress compared to a formal hearing. A mandatory settlement conference may also be held, where both sides discuss the claim and try to find a solution.

ADR is faster and less formal than a hearing. Having a lawyer during this process is helpful. They will explain your options and ensure you are treated fairly.

Formal Hearings

If no agreement is reached through mediation or other methods, the next step is a formal hearing. This is like a small trial where you present your case to a workers' compensation board judge.

At the hearing, you can share evidence, such as medical records, and explain why your workers comp claim should not have been denied. The insurance company will also present its side. The judge listens to both sides and then makes a decision.

A hearing can feel overwhelming, but having an experienced attorney makes a big difference. Your lawyer will prepare your case, speak for you, and make sure you have the best chance to win and get your workers' compensation benefits.

FAQs

Your claim could be denied for reasons like late reporting, missing medical records, or disputes about how the injury happened. Reviewing the denial letter can help you understand the specific reason.

Start by reviewing the denial letter carefully. Then, consult an experienced attorney to discuss your options for filing an appeal or strengthening your case.

Yes, you can appeal the decision. The appeals process may include filing forms, gathering evidence, and attending a hearing with the workers' compensation board.

The deadline for filing an appeal depends on your state. Check your denial letter or ask a lawyer to ensure you meet the timeline.

While not required, having a lawyer improves your chances of success. They can handle the process, gather evidence, and represent you in hearings.

Contact Our Washington, D.C. Workers' Comp Lawyer for a Free Consultation

Contact our Washington, D.C. workers comp lawyer for a free consultation

If your workers' comp claim was denied, don’t face the process alone. May Jung Law Personal Injury Lawyers are here to help you fight for your rights and ensure you receive workers' compensation benefits. Our experienced team understands how frustrating a denial can be and is dedicated to helping you secure the compensation you deserve.

We handle everything, from gathering evidence to representing you in hearings. Our goal is to help you recover medical expenses, lost wages, and other costs tied to your injury. We fight to ensure you get fair compensation for your claim through appeals or negotiations.

Contact us today for a free consultation. Let us review your case and explain your options. Call now for help securing the benefits you need. We’re here to support you every step of the way.

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LaRuby May
PERSONAL INJURY LAWYER
LaRuby May, born in Pensacola, Florida, to Reverend Theophilus May and Mary J. May, has been a changemaker for over 30 years. As a lawyer, entrepreneur, developer, teacher, and strategist, she co-founded the May Jung law firm with Je Yon Jung to advocate for people of color and empower their participation in the civil justice system.
Previously, she was a founding member of May Lightfoot, PLLC, representing clients in worker’s compensation and complex litigation. A founding board member of Shades of Mass, she also belongs to the National Bar Association, Women’s Bar Association, and UDC Law Hall of Fame.

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