How To Appeal a Denied Workers' Compensation Claim

If you have been hurt on the job or suffered an illness from work-related duties, you expect to get workers’ compensation benefits. However, there are times when your claim can be denied.

Unfortunately, not all claims are approved on the first try. Don’t lose hope if your workers’ comp claim has been denied. You have the right to appeal the decision and fight for the benefits you deserve. Let’s examine the steps needed to appeal a denied workers’ compensation claim.

The Denial Letter

Denials are common. According to a 2018 Lockton Analytics study, around 7% of all workers’ compensation claims were denied between 2013 and 2017. About 67% of initial denials were paid within the year, according to that same analytic report. So, there is hope if your workers’ comp claim has been denied.

After you send your form for workers’ compensation, you will either receive an approval or denial. That letter should provide a reason for the rejected claim. Sometimes, it can be an easy issue to resolve, such as you need to include more medical documentation. Other times, there could be another reason for this denial, such as there’s a dispute about whether the injury resulted from your work duties.

In any case, you will want to read over the denial letter carefully. It will act as a guideline for the next steps you need to take for your claim, such as:

• How and when you can appeal
• Any accompanying documents required
• The appeal deadline, which could be anywhere from 30 to 90 days away

Now that you have the denial letter in hand, what can you do to appeal a denied workers’ compensation claim? Let’s look at a few of these options.

Contact the Insurance Company

While you have the right to file an appeal, you may want to reach out to your employer’s insurance company. With a phone call or email, you can fully understand the reasons behind the denial. Everything from insufficient evidence, missed deadlines, or other issues could have led to these decisions.

Many times, a conversation with the insurance company can often resolve these misunderstanding. Also, it can give you an opportunity to provide additional information or documentation to support your claim.

If you decide to talk to the insurance company, make sure to take detailed notes during your conversation. This documented communication may be valuable if you need to escalate your appeal to a higher level or seek legal assistance in the future.

File the Workers’ Comp Appeal

If reaching out to the insurance company has not yielded a reasonable result, you may have to take a more formal approach. This is the time to file a formal appeal. Each state will have a specific set of rules to appeal a denied claim.

In almost all cases, you will need to submit a written appeal. In doing so, you will need to outline why you believe the denial was wrong. Make sure to be as specific as possible. You will want to include the facts of the incident, your medical record, witness statements, and anything else that can be relevant to your claim.

Along with that, you need to stick to the deadline specified in the denial letter. Typically, you will have anywhere from 30 to 90 days to appeal. If you miss this deadline, that could jeopardize your chances of a successful resolution.

Depending on your state, your formal appeal could be resolved through mediation or at a hearing.

Mediation and Your Workers’ Compensation Claim

In some states, you may be able to use mediation as an alternative to attending a hearing. California, Florida, and Michigan are a few states that have this requirement. In these situations, a third party will try to bridge the gap between you and the insurer.

Many times, you will have to request the mediation process. Like any other court hearing, you can present your case, and the insurer will respond. Your mediator’s goal for the session is to help you and the other party reach a mutually beneficial solution. Mediation is less adversarial than traditional hearings and can often lead to quicker results.

A Formal Workers’ Comp Hearing

If the mediation does not resolve your issues, or your state does not require it, you will have to attend a formal hearing. You will be given a date for a hearing soon after you file the appeal. An administrative law judge will preside over this hearing.

You have the right to present your evidence, including medical records, witness accounts, and photographic or video evidence. Make sure you’re fully prepared to state your case and answer any questions from both the judge and the insurer’s legal representative.

After that, the judge will review the evidence and make a decision. You’ll be able to receive your benefits if they rule in your favor. However, if they deny your claim, you may need to file an additional appeal.