Workers Comp Denied? Your Next Steps

Workers’ compensation system was put in place to help people injured on the job recover from their injuries and be compensated with the benefits they deserve for the incident. What happens when the system doesn’t go in the injured workers favor? What happens when their claim is denied and is there anything that can be done to change it? This article will talk about why workers’ comp is denied and the steps in the appeals process.

One of the first things that might happen after you put in a claim for workers compensation is you receive a letter of denial. In the letter of denial it should state the reason your claim is being denied. Let’s look at some common reasons that workers comp is denied: 

  • Lack of evidence that the injury is work related
  • No medical treatment
  • Employer disputes claim
  • The specific injury is not compensable
  • Claim was not filed in time
  • Injury was not reported in time

In the case of lack of evidence that the injury is work related, another medical exam might be able to help your case. It is also very important to seek medical care when injured at work, as in most cases it is a must to seek medical treatment when claiming workers’ compensation. You workers’ compensation claim can also be denied by your employer claiming that the injury happened outside of work or during horseplay. In the case of the injury not being compensable it might be harder to prove a stress injury and more details and possibly more exams will be needed. having workers’ comp denied can also happen by not meeting the reporting time requirements, in NY state it is 30 days after the incident. Those are just some of the reasons a claim can be denied, there are many more.

Now that we know the most common issues for your workers’ comp being denied it is time to appeal the decision. In the denial letter there will be instructions as to how to appeal and the deadline. In New York the appeals process for a workers’ compensation denial is: 

“Either side may appeal the judge’s decision. This must be done in writing within 30 days of the decision. Three Board members review appealed cases. They may agree, change part of a decision or reject it. They may also return the case for more hearings. Insurers don’t have to pay lost wage benefits while the case is being reviewed by the three Board members. An insurer can accept part of a case and appeal another. In that instance, it must pay the accepted part of the award while the case is reviewed. The insurer must pay your wages and medical bills if your award is upheld by those Board members, even if it appeals the case further.

Either side may appeal that decision to the full membership of the Workers’ Compensation Board of Commissioners. If the full Board takes the case, it will either agree, change, or overturn the decision.

Appeals from Board decisions may be taken within 30 days to the Appellate Division, Third Department, Supreme Court of the State of New York.” The full text can be found here.

So what does that mean for your denied workers comp case? For the first part it means that you or your employer and their insurance can appeal the judges decision. The paperwork must then be completed and appealed in writing within 30 days. Your appeal will go in front of three board members for review. It is their decision to agree with it, amend it, or make your workers comp denied as well as return the case for more hearings. An important thing to note is that the insurers do not have to page lost wages while your case is in front of the three board members. The insurers can accept part of a case and appeal another. In this complex part of the case the insurer must pay your wages and medical bills if your award is upheld, even if it appeals it further.

As you can see from the above excerpt the appeals process can be complicated and it could be said that it is best handled by an experienced workers’ compensation attorney. Was your case workers comp denied? You might feel like the deck is stacked against you, allow Ramos & Ramos to help get you the benefits you deserve. We don’t get paid unless you win. Contact us today at 716-810-6140.

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