My Workers Comp Case Was Denied, NOW What?

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My workers compensation claim was denied! NOW what?!

It's not uncommon for insurance companies to deny worker's compensation claims. In fact, they'll often do so, hoping that you'll just accept their decision and give up, saving them thousands of dollars in benefits that they would otherwise have to pay you. Don't laugh. It happens all the time and it pays to fight back. Approximately 47% of injured workers who received settlements for their case initially had their claim denied. Which means you have a good chance of getting benefits if you're willing to fight back against their decision.

But what's the step by step process for beating the big bad insurance company? How can you make sure you win your case in court? And what mistakes do injured workers make that end up losing their claims entirely? We are going to answer all of those questions right now.

My name is Rex Zachofsky and I became a New York workers comp lawyer 17 years ago after getting injured on the job. If you're looking for a lawyer to help you with your claim for New York State Workers compensation benefits, please give me a call at 212-406-8989 to schedule a free consultation.

Why Was My Claim Denied?

If your workers comp claim gets denied, the most important question is “why”.

There are a lot of reasons why a claim might get denied, and the answer will determine how you appeal the decision. You should be able to find an explanation in the notice of denial sent by the insurance company. Some of the most common reasons include:

  • Preexisting conditions
  • Missed deadlines
  • Being off-duty
  • Being intoxicated
  • Getting injured while away from work, and
  • Having an injury that isn’t work-related

By far the most common reason for a denied claim is that the injury was caused by a preexisting condition unrelated to work.

For example, if you hurt your back at work, but also have an old back injury from playing sports, the insurance company might try to argue that your current injury wasn’t caused by your job and is just your old sports injury acting up.

In this case, you would want to get medical records documenting the fact that your injury was in fact caused by something you did at work And if you have a different reason for your claim getting denied then you or your lawyer will likely need to gather a different form of evidence to support your argument. So if the insurance company claims that you were off-duty when the accident happened, get testimony from coworkers that you were in fact working. If they say that your injury was due to horseplay, try to get surveillance video proving otherwise.

As we’ll discuss in just a moment, you need to get the best evidence possible in order to successfully appeal your denial before a judge.

How Do I Appeal The Denial?

I have some good news and some bad news when it comes to appealing your workers comp denial.

The bad news is that the appeals process can take up to a year, depending on which state you’re in.

The good news is that appealing your denial works!

According to a recent study, 67 percent of initial denials convert into paid claims within about 12 months. So the odds are on your side!

Before you get started, you first need to decide if you’re going to appeal the decision by yourself or hire a workers comp lawyer. It’s not unheard of for an injured worker to appeal their own case, but most people hire a lawyer at this point. Not only do workers comp lawyers have a lot more experience navigating the complex process of an appeal, they also get you paid more: Injured workers who appeal by themselves receive an average settlement of only $12,400, while those who hire a lawyer receive an average of $18,200, almost 50% more!

Next is the appeals process, which will vary by state. Since I’m only familiar with the process in New York, I’ll share how it works here. The first step is to file a notice of claim with the New York Workers Compensation Board within two years of the date of injury, letting them know that you are appealing the denial of your claim. Next you need to gather evidence in support of your appeal, like we just discussed. This could include medical records, witness statements, video footage, testimony from witnesses, employment records, or anything else that might convince a judge to reverse the insurance carrier’s decision.

If you or your lawyer are able to gather enough evidence to make a strong case, chances are you won’t need to attend a hearing. Approximately 82% of workers of injured workers with denied claims are able to resolve their cases through settlement talks with the insurance company. That means only 18% go to a hearing.

Why? Because it’s expensive for the insurance company to go to court! They have a strong incentive to settle with you before things get that far. So once you have all the evidence you need to make a strong case, inform the insurance company and try to negotiate a satisfactory settlement.

If that doesn’t work, the next step is a formal hearing in which you’ll present your case to the judge through evidence you collected and the depositions of witnesses and experts. I’ve already covered how to ace your workers comp hearing in a separate video, so be sure to check that out if you haven’t already. I’ll include a link to it in the description below.

Finally, if the judge rules against your claim, you have 30 days from the date of the ruling to request a review by the Workers Compensation Board by submitting an application for board review. If they accept your request, a panel of board members will either hold up the judge’s decision, modify it, or rescind it entirely. They might also send the claim back to the judge for consideration. If the denial is upheld and you still want to appeal it further, you can take your claim to the Supreme Court of New York and New York Court of Appeals, but it’s very rare a workers comp case will come this far!

How Do I Win My Appeal?

So what are some of the things you can do to ensure your appeal is successful and you get all the benefits you’re entitled to?

One of the most simple and important mistakes to avoid is missing deadlines. The window for filing an appeal varies from state to state, but is typically around 30-90 days.

Another big one is failing to collect enough evidence to support your claim. The judge is going to remain unbiased toward you and the insurance company, so if you go into court expecting to use a sob story to sway them, it won’t work. You need to collect strong evidence that will support your case.

You should also be careful which doctor you choose for your medical evidence. This is often the most important evidence when making your appeal, so using a doctor who isn’t familiar with workers comp cases can result in the judge upholding your denial.

But by far, the best thing you can do to ensure you win your appeal is get a workers comp lawyer. We already learned that it will make you more money, but more importantly, it will also increase the chances that the appeal is successful.

A lawyer knows how to gather evidence, they have the authority and experience to negotiate the best possible settlement with the insurance company, and if you take your case to a hearing then they know to present your case to the judge in the most effective way possible.

So if you or a loved one have had your claim denied here in New York and would like to set up a free consultation with an experienced lawyer who will get your denial overturned, give me a call at 212-406-8989 today. Our conversation is confidential, costs you nothing, and can potentially result in thousands more in benefits than you would otherwise get on your own!

And if you plan on appealing your denial, then chances are you will end up negotiating a settlement with the insurance company.

But if you don’t have any experience negotiating, the insurance company will likely take advantage of that fact and convince you to accept less money than your case is worth.

Don’t fall for it! Watch my other video on how to negotiate a big workers comp settlement so you’re prepared to get all the benefits you’re entitled to.

I’ll include a link to that video here. Click to watch it now and I’ll see you there!


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