What to Do if Your Workers' Comp Claim is Denied

Your workers’ comp claim was denied. Now what? Your best course of action is to appeal the decision. Each state has an appeal process, but each state also has its own way of handling appeals. In some states it’s as easy as submitting a form online. In other states you may need multiple forms and a court hearing. Knowing how to navigate your state’s specific to-dos will go a long way toward helping you successfully win benefits — and decreasing your stress levels during the process.

What to do if your workers’ comp claim is denied 

When your workers’ comp claim is denied, you may still be able to get benefits. But you’ll need to go through the appeals process.

Each state handles appeals in a slightly different way. The general process you can expect is to file an appeal form with your state’s workers’ compensation board before attending a hearing to explain why you qualify for benefits. However, some states require multiple forms, each with their own deadlines.

If you’re appealing a denial, your best option may be to find a workers’ comp lawyer. They will know exactly how the appeal process works in your area and they can do the heavy lifting for you. They’ll also help you fight for the medical coverage and payments you need to cover expenses while you recover.

To give you an idea of what that can look like, let’s look at two examples — Pennsylvania (easier end of the appeal spectrum) and California (more complicated appeals process).

Workers’ comp appeals in Pennsylvania

In Pennsylvania, appealing a denied workers’ comp claim means filing Form LICB-2526. You can do this online with the Workers Compensation Automation and Integration System (WCAIS) or by mailing the completed form — along with your Workers’ Comp Judge’s Decision — to the Workers’ Compensation Appeal Board.

You need to do this within 20 days of the circulation date printed on the first page of your Judge’s Decision.

Workers’ comp appeals in California

In the Golden State, you need to file two forms to get in front of a judge to hear your appeals case.

The first form is the Application for Adjudication of Claim. Fortunately, the state has a guide you can use to help you complete this key piece of paperwork. You’ll need to file that form at your county office for the Division of Workers' Compensation (DWC). Shortly after, you should get a notice from the DWC office that your application has been filed. That notice will include your assigned case number (it will start with “ADJ”).

Then, to actually get in front of a judge, you need to file a Declaration of Readiness to Proceed. Include your case number on that form.

The deadline for submitting your appeal application depends on the kind of appeal you make. You have 20 days if you want to file a petition for removal, which basically takes the claims adjuster or insurance company off the decision-making seat entirely. But you have one year if you’re filing a petition for reconsideration, which essentially asks the appeals board to review the insurance company’s decision.

Each DWC office has an information and assistance officer who can help you if you have questions, but appealing a workers’ comp denial comes with a fair bit of paperwork and deadlines. Hiring a good workers’ comp lawyer can really help you through the process. There are also no upfront costs for you because a lawyer won’t get paid until after you win benefits.

Common reasons for workers’ comp claim denial

If you’re dealing with a denied workers’ comp claim, the first step is to find out why it was denied. Here are some of the most common reasons for a workers’ comp denial:

• You missed the deadline to report an injury or file a claim (these are hard to appeal).

• Your injury didn’t happen at work or in the course of your job.

• You never stopped working or didn’t miss much time after your injury.

• Your job didn’t qualify for workers’ compensation benefits.

• You didn't file your claim until after you quit or were fired.

• You didn’t take the required steps for benefits, like visiting a doctor approved by your employer’s insurance company.

• You have inconsistencies between your claim and the doctor’s medical report.

If your claim was denied for a reason you can’t fight but you’ll be unable to work for at least a year because of your injury, you can also explore benefits through Social Security Disability Insurance (SSDI).

How many workers' comp claims get denied?

An estimated 10% to 50% of workers’ comp claims are denied, but each state runs its own workers’ comp program so rates vary widely across the country.

In California, recent legislative changes have helped to raise approval rates, and less than 6% of claims were denied in 2019 (94.1% approval rate).

In Oregon, between 11% and 14% of workers’ comp claims were denied in the past decade. That denial rate has also ticked down slowly in recent years.

If you switch over to Massachusetts, rates look less favorable for claimants. The state reports that about half of workers’ compensation claims are disputed or denied by an employer or their insurance company.

Other factors also affect workers’ com denial rates, like the type of injury or illness someone has. For example, the denial rate in Ohio for COVID-19 claims was 39% among self-insured employers in 2022.

What happens to medical bills when workers' comp is denied?

If your workers’ comp claim is denied and you don’t successfully appeal it, you’re on the hook for all of your medical expenses. That includes bills you’ve already paid, bills that were charged to the insurance company, and any bills from future treatment.

Going through the appeal process after a denial might be a hassle, but it can save you quite a bit of money. If your appeal is successful, your employer’s insurance company is responsible for all of the medical expenses related to treating your injury.

Get help appealing a denied workers’ comp claim

You’re not alone if your workers’ comp claim was denied. And you don’t have to navigate the complicated appeals process alone either. A local workers’ comp lawyer will help you avoid common pitfalls and guide you toward your best shot at claim approval.

To find out if working with a lawyer would benefit you, take our quick workers’ comp benefits quiz. Our team will reach out as soon as possible to learn more about your situation and connect you with an experienced lawyer near you. There are no upfront costs and you don’t have to work with our lawyers if you don’t want to.

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