Flevy Blog is an online business magazine covering Business Strategies, Business Theories, & Business Stories.

What If Your Workers’ Comp Claim Is Denied?

Editor's Note: Take a look at our featured best practice, Human Resources Strategy Framework: Business Value Creation (101-slide PowerPoint presentation). One of the key success factors of high performing organizations is putting their people first. Today HR executives are challenged to develop efficient and effective powerful solutions to the people side of business. However it remains difficult to determine the exact contribution of the HR function [read more]

Also, if you are interested in becoming an expert on Human Resource Management (HRM), take a look at Flevy's Human Resource Management (HRM) Frameworks offering here. This is a curated collection of best practice frameworks based on the thought leadership of leading consulting firms, academics, and recognized subject matter experts. By learning and applying these concepts, you can you stay ahead of the curve. Full details here.

* * * *

Workers’ compensation, also referred to as workers’ comp, covers injuries that happen at work. This can include tasks that are related to work, such as using company vehicles.

Workers’ comp insurance most commonly covers traumatic injuries such as slip and fall accidents. Occupational injuries, which are illnesses or injuries that occur over time, are also often covered by workers’ compensation. The top three causes of work-related injuries, which make up more than 84% of nonfatal injuries involving time away from work, include overexertion, slips, trips, and falls, and contact with equipment and objects.

Most states require employers are covered with the average level of risk for a particular injury.

What happens if you file a claim and it’s denied, however?

Common Reasons Claims Are Denied

Your first step after a workers’ comp claim denial is to figure out the why behind the decision.

Some of the common reasons for denials include:

  • The injury wasn’t reported within the required timeframe. State law dictates how soon you’re required to report an injury, and it’s usually just a few days. Along with reporting the accident, which often has to be done in writing, state laws also have deadlines for filing the initial claim, which is usually within 30 to 90 days.
  • Employers may dispute someone’s workers’ compensation claim. For example, your employer might make the claim that you were hurt outside of work, or you were hurt under circumstances that disqualify you.
  • Some injuries aren’t eligible for compensation. As an example, it’s difficult to get compensation for stress-related injuries.
  • If you didn’t receive medical treatment, you’re unlikely to be able to get workers’ compensation.
  • Your claim might not have included adequate evidence that your injuries occurred at work.

Steps to Take after a Denial

After your claim is denied, you should, as was mentioned, figure out why. You should receive a letter that tells you why.

It may be a simple problem, such as a mistake with paperwork that you can fix relatively easily.

More commonly, you’ll have to appeal the denial.

How to Appeal a Denial

The letter telling you why your claim was denied should also give you information on how to appeal your denial. Go over it carefully—every state has its own appeals process.

Usually, the first part of the appeals process is a hearing in front of an administrative law judge.

At this hearing, you would present medical evidence and any other evidence you might have supporting your claim.

Then, based on your state, there are other levels of appeal that go beyond the administrative level.

You will have a state deadline for filing an appeal, just like you did for the initial claim.

Should You Get a Lawyer?

If your claim was denied for something simple that you can clear up pretty easily, then no, you don’t need a lawyer. Otherwise, it’s possible that you need an experienced work injury lawyer. If this is your case, Greenberg and Ruby Injury Attorneys can help in these situations.

It’s important when you’re going through the appeals process that you’re doing everything correctly and on-time.

An attorney is going to understand the ins and outs of what often amounts to a complex legal situation.

An attorney can help you gather evidence and build a strong case for your appeal.

Finally, there’s also a different scenario to be aware of, which is reopening a workers’ compensation claim.

Reopening a claim is different from an appeal of a denied claim.

You might reopen a claim because your injury has returned or gotten worse, or there’s new evidence that’s come to light, for example.

There are also time limits in place, set by the state, for how long you have to reopen a claim. These are usually up to seven years from the date your original claim was filed—not the date of your injury.

If you’ve been paid in full and a release is signed by you, then your case may be considered closed, and you can’t reopen it.

As is the case with everything else related to workers’ compensation, the process to reopen a claim varies based on the state.

Approach a denial with the knowledge that an insurance company is not in a rush to pay out benefits. There’s a high likelihood they’ll deny your claim if there’s even a small doubt about your injuries.

If you do receive a denial, you might contact an attorney who can source the proper medical records and cite employment law that’s relevant to your case.

44-slide PowerPoint presentation
The Fiaccabrino Selection Process is a powerful methodology for interviewing and screening the best people for your organization. The objective is to select those people who will be the highest performers with the lowest turnover. (Whereas the methodology was originally developed for a [read more]

Want to Achieve Excellence in Human Resource Management (HRM)?

Gain the knowledge and develop the expertise to become an expert in Human Resource Management (HRM). Our frameworks are based on the thought leadership of leading consulting firms, academics, and recognized subject matter experts. Click here for full details.

The purpose of Human Resources (HR) is to ensure our organization achieves success through our people. Without the right people in place—at all levels of the organization—we will never be able to execute our Strategy effectively.

This begs the question: Does your organization view HR as a support function or a strategic one? Research shows leading organizations leverage HR as a strategic function, one that both supports and drives the organization's Strategy. In fact, having strong HRM capabilities is a source of Competitive Advantage.

This has never been more true than right now in the Digital Age, as organizations must compete for specialized talent to drive forward their Digital Transformation Strategies. Beyond just hiring and selection, HR also plays the critical role in retaining talent—by keeping people engaged, motivated, and happy.

Learn about our Human Resource Management (HRM) Best Practice Frameworks here.

Readers of This Article Are Interested in These Resources

Excel workbook
The Human Resources (HR) Policies Toolkit includes a set of best-practice templates, step-by-step workplans, and maturity diagnostics for any HR Policies related project. Please note the above partial preview is ONLY of the Self Assessment Excel Dashboard, referenced in steps 1 and 2 [read more]

66-slide PowerPoint presentation
26-slide PowerPoint presentation

About Shane Avron

Shane Avron is a freelance writer, specializing in business, general management, enterprise software, and digital technologies. In addition to Flevy, Shane's articles have appeared in Huffington Post, Forbes Magazine, among other business journals.

Complimentary Business Training Guides

Many companies develop robust strategies, but struggle with operationalizing their strategies into implementable steps. This presentation from flevy introduces 12 powerful business frameworks spanning both Strategy Development and Strategy Execution. [Learn more]

  This 48-page whitepaper, authored by consultancy Envisioning, provides the frameworks, tools, and insights needed to manage serious Change—under the backdrop of the business lifecycle. These lifecycle stages are each marked by distinct attributes, challenges, and behaviors. [Learn more]

We've developed a very comprehensive collection of Strategy & Transformation PowerPoint templates for you to use in your own business presentations, spanning topics from Growth Strategy to Brand Development to Innovation to Customer Experience to Strategic Management. [Learn more]

  We have compiled a collection of 10 Lean Six Sigma templates (Excel) and Operational Excellence guides (PowerPoint) by a multitude of LSS experts. These tools cover topics including 8 Disciplines (8D), 5 Why's, 7 Wastes, Value Stream Mapping (VSM), and DMAIC. [Learn more]
Recent Articles by Corporate Function






The Flevy Business Blog (https://flevy.com/blog) is a leading source of information on business strategies, business theories, and business stories. Most of our articles are authored by management consultants and industry executives with over 20 years of experience.

Flevy (https://flevy.com) is the marketplace for business best practices, such as management frameworks, presentation templates, and financial models. Our best practice documents are of the same caliber as those produced by top-tier consulting firms (like McKinsey, Bain, Accenture, BCG, and Deloitte) and used by Fortune 100 organizations. Learn more about Flevy here.

Connect with Flevy:


About Flevy.com   /   Terms   /   Privacy Policy
© . Flevy LLC. All Rights Reserved.