Getting a workers’ compensation insurance claim denied can be the straw that breaks the camel’s back in more ways than one. You’re already injured and unable to work with medical bills piling up, so your next move is to appeal the workers’ comp claim denial. However, to be successful, you need to follow state regulations and timelines.
We can’t lay out the specifics for all 50 states, but we can give you some general advice to help you get the appropriate workers’ comp benefits. Here are the five steps on how to appeal a workers’ comp claim denial.
1. Find Out Why Your Claim Was Denied
There is a process that every workers’ compensation claim follows and a rationale behind every decision. You need to learn why your claim was denied in the first place to best appeal it. Possible reasons that a claim may be denied include:
- Your injury is not work-related
- Your injury was caused by a preexisting condition
- The location and time of your injury is in dispute
- Your employer or your employer’s insurer dispute that any injury occurred
- You missed deadlines or incorrectly filed forms
Understanding the rationale behind the denial is the starting place for your appeal. After all, if the only reason that the claim was denied was because a form wasn’t filed properly, you may be able to reopen the case, file the form, and continue with the process.
However, if there are doubts about the nature or cause of your injury, then you’ll have to compile data to prove your case. To get the right information about the denial, read the denial letter and call your employer’s insurance carrier. The denial letter may or may not state why the claim was denied, but the insurance carrier has to give you this information upon request.
2. Ask the Insurer to Review Its Decision
To get the insurance carrier to review its decision, you’ll need to request a review in writing. This can be a simple letter but should be formalized to notate filing dates and times, ensuring you meet state rules.
In your letter, include your case number and a brief description of how you were injured. Acknowledge that you received a denial letter and that you would like to appeal the decision by having the carrier review the denial. Ask the insurance carrier to reconsider its position and state the reasons why you feel that this was denied incorrectly.
If you have information that will help sway the carrier in your favor, supply them with the documentation. In the event that forms are missing, include the requisite forms with the letter. If there is a question about the details of your injury, provide the insurance carrier with any documentation that might help your case. This might include a third-party doctor’s evaluation regarding your injuries and disability.
3. File a Formal Appeal With Your State Board
Workers’ compensation is overseen by the state workers’ compensation board or a similar oversight body that makes sure employers have workers’ comp insurance and are following the rules when it comes to paying claims. It also keeps insurance carriers honest about denying claims that have merit behind them. In short, they protect the employee’s interests when necessary.
The denial letter should have details about filing a formal appeal with the state board. These details should include:
- What forms are required to start an appeal
- Where those forms need to go
- How long you have after the denial to file your appeal
If your denial letter doesn’t have these, go to the state workers’ comp board and search “file an appeal.”
Most state boards make this very clear on their homepage and want employees to be able to find the resources they need quickly. Complete the required appeal forms and submit them to the board within your appeals timeline. This needs to be done within 30 days but varies from state to state.
Pro tip: Just about every state has an office—usually called the ombudsman—dedicated to helping people navigate the workers’ comp claims process. Services range from answering questions about benefits to assisting parties who do not have representation in a claim appeal. The ombudsman usually is separate from the state board, but you should still be able to find contact information for it on the state board’s website.
4. Gather Documentation to Support Your Claim
Once you file a formal appeal, the review process starts. This process typically involves your state board evaluating your case as presented by you and your employer’s insurance carrier and taking a closer look at:
- Your employer’s incident report
- Your initial diagnosis
- The prognosis and ongoing treatment plans
Don’t rely on the insurance carrier to have or provide all the information. Ask your employer for a copy of the incident report—assuming you’re not in a state that requires employers to provide one to injured workers—and get copies of your entire medical file from the doctor. Talk to witnesses and get signed letters stating they saw the accident happen at work and describing the circumstances. You’ll want to provide all of this to the state board review.
The steps that follow the review board’s evaluation can vary greatly by state. Your state may require:
- A formal hearing: While a hearing may not be a formal lawsuit, it can feel very much like one with both sides presenting evidence, witness testimony, and legal arguments. California is an example of one state that requires a hearing in front of the Workers’ Compensation Appeals Board judge who makes a decision after listening to the evidence.
- Mediation: Some states prefer mediation and may even require mediation prior to a hearing. Mediations tend to be more informal than hearings and are usually arbitrated by a neutral third party.
In either situation, you want to go in prepared with all your documentation.
5. Consider Hiring a Workers’ Compensation Attorney
You may want to consult an attorney to help you understand your rights fully. Technically, when a company has workers’ comp insurance, employees cannot sue them for injuries, but there are exceptions. An experienced workers’ comp attorney can best advise you regarding your rights.
One action your attorney might take is to get an independent medical specialist to evaluate your condition. These specialists can then be expert witnesses to support your case. The great thing is that workers’ compensation attorneys often work for a fee that is only paid when they win your case and can negotiate a higher settlement to account for their fees. This helps you get the most money that you are entitled to for your injuries.
Pro tip: The time to get an attorney is before you go into a formal hearing or mediation to get help identifying key issues and persuasive arguments for your case. Moreover, you may lose any appeals rights once the hearing is complete.
Just because your workers’ compensation case was denied doesn’t mean that you have no options available. You can appeal your case directly with the insurance carrier, but you also have the right to take matters up with the state insurance board. With the right documentation and support, you can get a denial changed into an approval to get you the medical attention and financial support you deserve.