What Can I Do if My Workers’ Compensation Claim Is Denied?

Getting hurt on the job can leave you with many questions. Not knowing how long you will be out, combined with the injury itself, can be a frustrating experience. Having your Workers’ Compensation claim be denied can make matters worse.

Fortunately, there is an appeal process that you can go through should your Workers’ Compensation claim be denied. It is a complex process and requires a reputable lawyer on your side to help navigate the case. However, the first step to appealing a denial is to understand why that decision was reached.

In New Jersey, the deadline to reporting your injury to your employer is 90 days from the date of your injury. Your employer will then notify their insurer about the injury, who will then send a letter to you within 30 days notifying you of their decision whether it is approved or denied. If the claim is denied, the insurer will specifically explain what the reason was for the denial, which may include:

  • The employee had a pre-existing condition that did not occur at work or was not aggravated by an injury at work.
  • The injury was not properly documented, or the paperwork was mishandled either by the employer or insurer.
  • The employee’s injury did not occur within the scope and course of employment, or the injury took place completing a task not related to work.
  • The injury to the employee happened intentionally and not within the scope of employment.
  • Medical care received is not related to a work-related injury.
  • Injury is minor and not as severe as claimed, and no work should be missed.
  • The injury occurred because of the influence of drugs or alcohol.

It is important to understand the reason behind the denial, especially if you plan on appealing. That is why having the help of a lawyer is imperative to appealing a denied claim. A lawyer can help you understand why the insurer’s decision was reached and how to refute that decision properly.

A Workers’ Compensation claim can be denied at any time for a myriad of reasons. Some claims have been denied because of incorrect paperwork, or the employer did not have the correct coverage. These claim denials are usually miniscule and do not take much to regain coverage. Contacting your employer or speaking with a representative of the insurance company usually fixes these types of issues.

However, there are times when the insurance company denies a claim because of more complicated reasons. These would require a lawyer. Insurance companies may deny a claim if they believe the employee is not injured and may require you to receive an independent medical examination (IME).

An IME is normally issued by an insurance company to prove the severity of your injury and is done by a doctor either by their choosing or from a list of doctors they provide. You are then able to choose from their list of doctors that best suits your needs. This IME gives you the opportunity to explain your symptoms and the severity of your injury. It is recommended that you bring all the medical documentation you have pertaining to your injury so the doctor performing the IME can fully understand.

During the IME, the doctor will determine whether your injury puts your in partial or permanent disability and what your recovery time looks like. However, the IME is usually used by the insurance company to deny an employee permanent disability coverage.

The only time an employee can use their own doctor is during an emergency. After the emergency, however, the insurance company may then choose the doctor next to handle treatment and recovery.

How to Appeal a Workers’ Compensation Claim Denial?

If your Workers’ Compensation claim has been denied, there are some important steps you must follow to get the appeal process going. In New Jersey, the Division of Workers’ Compensation gives you two options to file an appeal, either through an informal or a formal hearing. This is the point where you must work with a lawyer if you have not found one already, as the legal proceedings are extremely complicated.

Before filing the appeal, be sure to request more information from the insurer to further understand why you were denied. This is to ensure that you and your lawyer do not make the same mistake twice. Gather as much information as you can, including medical records, treatment plans, and witness information of your injury, and go through everything with your lawyer before filing your appeal.

You must file your appeal within two years of the injury. With an informal hearing, you file your Application for Informal Hearing form to the Division of Workers’ Compensation in New Jersey. Here, you and your lawyer, as well as the employer or the employer’s insurance company, will meet to assess your claim.

Formal hearings take longer and require you to file a Claim Petition, and the hearing will take place in front of a judge. The judge will then decide on your injury claim, will hear testimonies from your employer, yourself, witnesses, and medical experts and will consider all evidence. This is very similar to a trial, where you can challenge evidence, as well as cross-examine witnesses and experts.

If a judge in a formal claim hearing denies your claim, you still have the right to appeal that decision. This will be done in the New Jersey Appellate Division of the Superior Court, which will likely involve an even more complex case.

New Jersey Workers’ Compensation Lawyers at Kotlar, Hernandez & Cohen, LLC Help Workers Whose Claims Have Been Denied

A workplace injury is always difficult, and it can get even more complicated if your Workers’ Compensation claim is denied. Our New Jersey Workers’ Compensation lawyers at Kotlar, Hernandez & Cohen, LLC are here to help. Call us at 856-751-7676 or fill out our online form for a free consultation. Located in Mount Laurel, Cherry Hill, Trenton, and Vineland, New Jersey and Trevose, Pennsylvania, we serve clients throughout New Jersey and Pennsylvania.

Share this post

Want to join the team?

We’re always looking for new talent. Please email a resume and cover letter to [email protected].