Workers' Comp Claim Denied — What to Do Next

Claims are denied for many reasons, some legitimate and some not. Common denial reasons include: the insurer disputes that the injury is work-related; the injury was not reported within the required deadline; you missed or declined medical appointments; there is a question of whether you were actually an employee; the injury occurred during horseplay or willful misconduct; or the insurer simply disputes the extent of your disability.

Some denials are issued in bad faith or based on incomplete investigation. The mere fact of a denial does not mean you have no valid claim.

Step 1: Review the denial letter carefully. The letter must state the specific reason for denial and your appeal rights including deadlines. Missing the appeal deadline is fatal to your case.

Step 2: Gather evidence. This includes medical records documenting your injury, incident reports, witness statements, and any documentation showing you reported on time.

Step 3: File your appeal. In most states, you appeal to a workers' compensation board or court by filing a formal appeal or application for hearing. Some states require mediation or informal resolution first.

Step 4: Attend your hearing. Present your evidence and medical records. The burden is typically on you to prove the injury is work-related and the extent of your disability.

The insurance company's medical examination (IME) is performed by a doctor paid by the insurer and often minimizes your impairment. You have the right to get an independent medical examination from your own doctor and present that evidence at a hearing.

In many states, the treating physician's opinion is given more weight than the IME physician's opinion because the treating physician has an ongoing relationship with you and more information about your condition. Having strong medical support from your treating physician is often the most important factor in successfully appealing a denial.