What to do if your workers’ compensation claim is denied

December 20, 2022

Most states require that employers carry workers’ compensation insurance. Therefore, when you got injured at work, you are typically entitled to these benefits.

However, there are times when the insurance company denies your claim. These are some steps you should consider if you receive a workers’ compensation claim denial.

Learn why you received a denial

To qualify for workers’ compensation , you typically have to meet specific state requirements. For example, some states do not pay for psychological conditions or cumulative trauma. In addition, these claims have reporting and claim filing deadlines. They also have specific guidelines for the information you need to include, and it needs to be accurate.

The insurance company may also question whether the injury is truly work-related. Finally, if your doctor released you for regular work, you left your job or you were under the influence at the time of the accident, you may receive a denial.

Gather your documents

Review your initial claim to ensure it is accurate and thoroughly complete. Then, gather all the relevant documents to prove your case. For example, collect your medical records, any photographs or video taken of the incident and the area where it occurred, witness statements and initial accident report.

File an appeal

You have between 60 and 90 days to appeal your claim denial. In California, you only have 60 days, but review your denial letter for any deadline updates. Contact the insurance company by phone. You may only need to clarify a few details on your claim. However, prepare to write a formal appeal.

Once you file an appeal, get ready to present your case before an administrative law judge at the labor department or workers’ compensation board. However, you may wait up to 14 months from your appeal for a final decision.

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