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 workers' compensation claims. In fact, they often hope you'll accept their decision without a fight, saving them thousands of dollars in benefits they would otherwise owe you. It happens all the time, but you don't have to accept their decision. Approximately 47% of injured workers who received settlements for their case initially had their claim denied. This means you have a good chance of getting benefits if you're willing to fight back.

But what's the step-by-step process for challenging the insurance company? How can you ensure you win your case in court? And what mistakes do injured workers make that can cost them their claims entirely? Let's break it down.

Why Was My Claim Denied?

If your workers' comp claim gets denied, the most important question is, "why?" Understanding the reason for the denial will determine how you appeal the decision. You should find an explanation in the notice of denial sent by the insurance company. Common reasons include:

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

The most common reason is that the injury was caused by a preexisting condition unrelated to work. For example, if you hurt your back at work but have an old sports injury, the insurance company might argue your current injury isn't job-related but rather your old injury acting up.

In this case, you'd need medical records documenting that your injury was caused by something you did at work. If the reason for denial is different, such as being off-duty, you'd need evidence like coworker testimony to prove you were working. Gathering the best possible evidence is crucial for successfully appealing your denial before a judge.

How Do I Appeal the Denial?

The appeals process can be lengthy, potentially taking up to a year, depending on your state. However, appealing your denial often works. According to a recent study, 67 percent of initial denials convert into paid claims within about 12 months.

First, decide if you’re going to appeal the decision yourself or hire a workers' comp lawyer. While it’s possible to appeal on your own, most people hire a lawyer. Lawyers have more experience with the complex appeals process and generally secure higher settlements: workers who appeal by themselves receive an average settlement of $12,400, while those with a lawyer receive an average of $18,200.

In New York, the first step is to file a notice of claim with the New York Workers Compensation Board within two years of the injury date, indicating that you are appealing the denial. Next, gather evidence to support your appeal, such as medical records, witness statements, video footage, and employment records.

If you gather enough evidence to make a strong case, you may not need a hearing. About 82% of denied claims are resolved through settlement talks with the insurance company because going to court is expensive for them. If negotiations fail, you’ll present your case to the judge through the evidence and witness testimonies. If the judge rules against your claim, you have 30 days to request a review by the Workers Compensation Board. They may uphold, modify, or rescind the judge’s decision, or send the claim back for further consideration. Appeals can go to the Supreme Court of New York, but this is rare.

How Do I Win My Appeal?

To ensure your appeal is successful and you receive the benefits you're entitled to, avoid these common mistakes:

  • Missing Deadlines: The window for filing an appeal varies by state but is typically 30-90 days.
  • Insufficient Evidence: Judges remain unbiased, so strong evidence is necessary to support your case.
  • Inappropriate Medical Evidence: Use a doctor familiar with workers' comp cases for your medical evidence.

The best way to increase your chances of a successful appeal is to hire a workers' comp lawyer. They can gather evidence, negotiate the best settlement, and effectively present your case to the judge.

If you've had your claim denied in New York and need an experienced lawyer to help overturn it, call me at 212-406-8989 for a free consultation. Our conversation is confidential, costs you nothing, and could result in thousands more in benefits than you’d get on your own.

Negotiating a Settlement

If you plan on appealing your denial, you will likely end up negotiating a settlement with the insurance company. Without negotiation experience, the insurance company might take advantage and convince you to accept less than your case is worth. Don't fall for it! Watch my other video on negotiating a big workers' comp settlement to get all the benefits you deserve. Click to watch it now and learn more.

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