How to Handle a Workers Comp Claim Denial

How to Handle a Workers Comp Claim Denial

When an accident does occur, your employer’s workers’ compensation insurance should cover the medical costs associated with it. But what happens when your workers’ comp claim is denied?

It can be disheartening and overwhelming when you receive a denial from the insurance company, so it’s important to know what steps to take. The good news is there are things that can be done in this situation, and this article will explain how to navigate a workers’ comp claim denial in an informed and effective way.

Call our North Carolina workers compensation lawyers today for help.

Review The Denial Letter

If your workers’ comp claim has been denied, the first step is to review the denial letter. This document should provide detailed information about why your claim was turned down. Ensure you understand why the insurance company believes you are not entitled to benefits.

When reviewing the letter, look for key phrases such as:

  • “Exclusion of coverage”
  • “Failure of proof”
  • “Time limit expired”
  • “No valid medical diagnosis”

These phrases will give clues as to what is missing in your claim and what still needs addressing. By understanding why your claim was denied, you can assess whether or not it can be appealed and how best to proceed with that process.

Appeal the Decision

Workers’ compensation claims can be a difficult process. If your claim has been denied, you will need to file an appeal. Filing an appeal means challenging the decision of the company or insurance company that denied your claim and asking them to reconsider.

The appeals process will vary depending on where you live, but generally, there are three steps.

File a Written Petition

You must file a written petition (also known as a Claim Review or Motion for Reconsideration) with the relevant workers’ compensation board in your state. This document must include why you believe the decision was wrong and any evidence that supports your claims.

Attend a Hearing

Once your petition is accepted, you and your employer will be called to a hearing before an administrative law judge. Both parties will present their case at this hearing, and the judge will decide.

Appeal the Ruling

If you still disagree, both parties can appeal it to the appellate court in their state. The appellate court’s decision is final, so ensuring that any evidence presented is accurate and compelling if you decide to pursue this option is important.

a workers comp claim can be denied for various reasons by an insurer

Seek Legal Advice

You might feel frustrated and lost if your workers’ comp claim is denied, but you’re not powerless. One of the smartest steps you can take to understand the denial and your situation is to seek legal advice.

A knowledgeable attorney can help you understand why your claim was denied and help evaluate if there’s a basis to challenge the decision. Plus, with their understanding of workers’ comp law and insurance claims procedures, they can assess any crucial evidence that needs to be presented to get your claim approved.

If you believe that there are extenuating circumstances related to your injury at work or wonder if a mistake was made in reviewing the initial claim paperwork, your lawyer helps determine if those issues should be addressed in an appeal or other action. Consulting with a legal expert provides valuable insight and further simplifies the process of getting compensated for any injury or illness related to your job duties.

Reasons Why Claims May Be Denied

A workers’ comp claim can be denied for a variety of reasons. Here are some of the most common ones.

Not Filing a Claim Within the Statute of Limitations

In North Carolina, you must file a workers’ comp claim within two years of your injury. If you don’t meet this deadline, you risk having your claim denied.

Not Providing Proof of Injury or Illness

For your workers’ comp claim to be approved, you must prove that your injury or illness is work-related and occurred within the course and scope of your employment.

Not Proving Causation

You must also provide evidence that shows that the injury or illness was directly caused by something at work, such as a specific incident or unsafe working conditions. Insurance companies do not respond well to hazy explanations or speculation of any kind.

Failure to Follow Post-Injury Protocols

Employees are expected to follow established workplace procedures after an injury is sustained, such as visiting a specific doctor, getting a second opinion, etc. Failure to do so can result in a denial of your workers’ comp claim.

Misrepresentation of Your Injuries

Workers’ compensation fraud is taken seriously. If an employee makes false statements about injuries or illnesses to secure benefits, the result will generally be an immediate denial of the claim by the insurance company involved in the case.

If any one of these conditions applies to you, it’s important that you contact an experienced attorney as soon as possible so that they can help you rebuild your case and get the medical care and financial assistance that you deserve.

Rules Regarding Deadlines and Appeals

If you’re dealing with a workers’ comp claim denial, it’s important to know the deadlines and appeals rules. Generally speaking, you have up to two years from the date of your injury to file a workers’ comp claim. If you don’t do so within this time frame, you won’t be eligible for benefits.

If you file a claim within the two-year window and it’s denied, you have three years from that date to appeal your decision. However, keep in mind that each employer is allowed to set their appeal deadline, which should be stated in the denial letter. If their timeline is shorter than three years, then that’s what you’ll need to follow.

You should also note that the appeals process isn’t automatic—you must properly submit an appeal application to get a hearing. From there, you’ll need to present evidence and testimony to support your claim at the hearing and wait for a decision from the court.

Understanding these rules can help ensure you take all necessary actions within the required timeframe and give yourself the best chance of receiving workers’ comp benefits.

Our North Carolina workers comp lawyers are here to help you.

Recent Posts

Workers' Compensation Lawyers Coalition

Let's get started with your


*While this website provides general information, it does not constitute legal advice. The best way to get guidance on your specific legal issue is to contact a lawyer. To schedule a meeting with an attorney, please call or complete the form here.


Give us a call



*While this website provides general information, it does not constitute legal advice. The best way to get guidance on your specific legal issue is to contact a lawyer. To schedule a meeting with an attorney, please call or complete the form here.