Common Reasons Your Workers’ Comp Claim Was Denied

Most people know that if they get hurt on the job, they should file a workers’ compensation claim for workers' comp benefits.

Your boss might tell you that you can file the claim for a workplace injury yourself. However, what he or she might not – and probably won’t – tell you is that winning a workers’ comp claim is very difficult. In fact, of the 14,270 claims filed between Jan. 2020 and Nov. 22, 2020, for Parts B and E, only 5,674 payments were made.

And this was only for those claims filed with the insurance carrier for the Division of Energy Employees Occupational Illness Compensation for those working for the Department of Energy in New York.

Part B is for those employees whose cancer was radiation-induced. Part E is for those who become ill because of exposure to toxic substances, such as chemicals, solvents, radiation, metals, and acids.

If you have a workers’ compensation claim in New York, contact us at (516) 997-0997 an experienced workers’ comp attorney at Terry Katz & Associates law firm. Our firm has the experience and resources to represent your interests on a contingency basis. The consultation is free, and you don’t pay for our legal advice and representation unless we win.

Common Reasons Why Claims Are Denied for Injured Workers

If we further break the statistics down, people filed 11,452 Part B claims. Of those, the EEOICP approved 5,044 and denied 5,831. New York denied more Part B (for Department of Energy) claims than it approved. The same happened for Part E claims. Workers and co-workers filed 2,818 Part E claims. New York approved 1,157 work-related injury claims and denied 1,369 claims.

The insurance company and/or the Workers' Compensation Board could deny your claim for any number of reasons:

• You did not formally report your injury to your employer prior to the appropriate deadline. As soon as you are hurt, even if you think your injuries are minor, you need to formally report the injuries to your employer within 30 days of your injury.
• You did not file your claim in time. Keep in mind that reporting your claim to your employer is not the same as filing a claim. The Board and the courts adhere to strict time limits. You have two years from the date of your injury to file a claim with the appropriate District Office.
• You did not seek medical treatment for your injuries. Even if the injury seems minor, you should always seek medical attention. Minor injuries could turn into significant injuries or even permanent disabilities hours or even days later.
• You received medical care, but it was not from an authorized provider.
• You filled out the paperwork incorrectly, or it was incomplete.
• You do not have enough medical documentation to support your claim for workers' compensation insurance.
• No witnesses saw the accident and are therefore unable to corroborate the event leading up to the accident.
• The law deems your injury as “not compensable.”
• The employer denies that the injury happened at work. Employer disputes further complicate the workers' compensation process and can also lead to a claim denial.
• The employer insists that you do not have enough evidence proving that the injury was work-related or insists that your injury was a pre-existing injury.
• The workers’ compensation insurer made a mistake or is purposely delaying the claims process.
• You took a blood test that showed positive for alcohol or drugs at the time of your injury.

Any number of these or other reasons could cause a denial of your claim. Some of the reasons might not be true or valid for your case, even though the Workers’ Compensation Board lists those reasons. When you schedule a free consultation with an experienced workers' comp attorney, we will advise you of your rights during the claim process.

What Are My Options if My Workers’ Compensation Claim is Denied?

If you filed a workers’ compensation claim after a workplace accident and received a denial letter, you still have some options. However, the next steps are complicated as you will have to show due cause as to why the denial is incorrect. Terry Katz & Associates, a workers' comp lawyer, has helped many people get the compensation they deserve after the Workers’ Compensation Board denied their claims, including filing an appeal. However, if you filed a Section 32 Agreement, which is a negotiation, and the insurance company approves it:

• You cannot appeal your case, even if you use a workers' compensation lawyer. If your condition worsens, you are responsible for your medical expenses and lost wages.

• If you run into a financial hardship sometime after the Board approves your Section 32 Agreement, you are responsible for your medical expenses and lost wages. 

• Additionally, if you settled your case, you cannot sue your employer or anyone else for injuries that unexpectedly continue or worsen. This applies to stipulation agreements, settlement agreements, and Section 32 agreements. 

Before you consider settling, whether via a settlement agreement or a Section 32 Agreement, be sure to review any disclaimer and discuss the claims process with one of our workers' compensation attorneys.

Can I Appeal a Workers’ Comp Denial?

As long as you don’t settle, you can file an appeal. The workers’ compensation insurer can also file appeals. Even after a workers’ compensation insurer accepts a claim and starts making payments, it can still dispute your claim. If it does, the examiners attempt to resolve the issues. If they cannot resolve the issues, the Board then sets a hearing in front of a workers’ comp judge.

During the appeals process, the judge reviews your wages and medical records and then makes his or her decision based on your injuries and job duties. If the judge agrees with the Workers’ Compensation Board, he or she denies your claim. You then have the option to file an appeal. If the judge rules in your favor, the Workers’ Compensation Board can also file an appeal.

If you decide to appeal, you have 30 days from the date of the judge’s decision to file that appeal. If you choose to retain an attorney, you will have to give the attorney time to review your entire case; thus, it’s not a good idea to wait until the last minute. Many workers’ compensation attorneys such as those at Terry Katz & Associates take cases on a contingency basis, which means you don’t pay anything upfront. 

After You File an Appeal

Once you file an appeal, your claim goes through an often-complicated process. Three Board members review your claim. During this process, your insurer doesn’t have to pay wage benefits.

If the Board disagrees with the lower court’s ruling, it can accept part of your claim and appeal the rest. You could receive benefits for the portion that the Board accepted but will have to still go through the appeal process for the unaccepted portion.

If the three Board members agree that your claim is valid, the insurer must pay your medical bills and wages, even if they decide to appeal again. You can also choose to appeal a second time. For the second appeal, the Board has to agree to take the case. It can then change the decision, agree to the previous decision, or completely overturn the previous decision.

When you file an appeal of a Board decision, you have 30 days to file the appeal in the Appellate Division in New York’s Supreme Court.

Discuss Your Workers’ Comp Denial with an Experienced Workers’ Compensation Attorney

The workers’ compensation process is fraught with deadlines. When filing appeals, you must be able to make a legal argument showing why the board and appellate judges should overturn the original decision. In most cases, you will have to show the appellate judges why you believe the Board erred in its decision.

If you or someone you love were denied workers’ compensation benefits in New York, a workers’ compensation attorney at Terry Katz & Associates has the knowledge and the resources to fight for your rights.

Contact us at (516) 997-0997 to schedule a free, confidential case review and learn more about your rights after a workers’ compensation denial.