Workers' Compensation Claim Denied: What to Do Next and How to Appeal

A denial is not the end. Many denied claims are approved on appeal, and the insurer's reason tells you what to prove. The most important step is to act before the appeal deadline, which is short in most states.

Read the denial for the reason

• The injury is not work related, or happened off the job.
• Late notice to the employer.
• The insurer disputes the medical diagnosis or says it was a pre-existing condition.
• The worker was an independent contractor, not an employee.
• Missing paperwork or a deadline.
• Alleged violation of safety rules or intoxication, which some states treat as a defense.

Immediate steps

1. Find the appeal deadline in the denial letter and calendar it.
2. Request your claim file and the medical records the insurer used.
3. Keep seeing your doctor, and tell every provider the injury happened at work.
4. Write a timeline of the injury, who saw it and when you told your employer.
5. Contact a workers' compensation lawyer. Many work on contingency and fees are regulated in many states.
6. File the appeal or request for a hearing with the state workers' compensation agency by the deadline.

Evidence that helps

• A doctor's written opinion that the injury is related to the work.
• Incident reports, witness statements and photos of the scene.
• Time cards and pay stubs that prove employment.
• Records showing you reported promptly.
• Prior medical records, if the insurer claims a pre-existing condition, to show a change or aggravation.

Money while you wait

Ask whether your health insurance will cover treatment while the dispute continues, and understand it may seek repayment if the claim is later approved. Short-term disability, state disability insurance, sick leave and unemployment may help if you qualify. Keep receipts for out-of-pocket costs, which may be reimbursed.

Protection from retaliation

Most states bar employers from firing or punishing a worker for filing a workers' compensation claim. If your treatment at work changes after you file, write down the dates and tell your lawyer. See our guides on workers' compensation versus third-party claims and on retaliation at work.

If the employer will not file the claim

Many states let you file directly with the agency. Report the injury in writing as soon as possible, and keep a copy. If the employer has no insurance, ask the agency about uninsured employer funds or a lawsuit against the employer.

A hypothetical denial and response

A warehouse worker hurts his back lifting on a Tuesday, tells his supervisor the same day, and sees the clinic on Thursday. The insurer denies the claim, saying the injury was not work related and that he had earlier back problems. His lawyer collects the incident report, a coworker's statement, and a doctor's letter that explains how the lift aggravated an old condition. The appeal then turns on the medical opinion and the prompt report, not on whether he had earlier pain.

Keeping the record clean

Be consistent when you describe the injury to doctors, the employer and the insurer. Small differences in how you tell the story are used to challenge a claim. Follow work restrictions, attend appointments and tell the doctor the injury happened at work. Avoid posting activity online that conflicts with your injury.

Frequently asked questions