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What To Do If My Workers’ Compensationensation Claim Is Denied?

What To Do If My Workers’ Compensationensation Claim Is Denied in New York

If you sustained an injury on the job, you may not only anticipate the benefits to which New York workers’ compensation law entitles you but also, you may count on them to support yourself and your family through your recovery.

For you, as for so many other individuals in your situation, a denial of benefits after sustaining workplace injuries can prove devastating. Fortunately, with the help of a skilled workers’ comp lawyer, a denial does not have to be permanent.

Workers’ comp is a no-fault system. What this means for you is that the law entitles you to benefits for select damages associated with work-related injuries, regardless of how the accident that caused your injuries occurred or who caused it.

In exchange for this peace of mind, you forfeit your right to sue your employer for compensation. Despite this, workers’ compensation denials can happen. In fact, according to one study, the rate of denials has increased since 2013.

If your workers’ comp is denied, do not panic. The good news is that, with the right help from an experienced workers’ compensation lawyer, you can reverse that decision. Not only that, but you may also receive more than what the insurance carrier may have paid you voluntarily.

Per the same study that assessed denial rates, two out of three rejected claims receive approval within the year. The payout on those is approximately 55% higher. The average cost of an accepted claim is $10,153. The average cost of an initially rejected but later approved claim is $15,694.

To receive approval and, hopefully, a larger amount, partner with a workers’ compensation law firm that has experience fighting denials and appealing decisions. Contact Pyrros & Serres, LLP to see how our law firm can protect your rights and recover the maximum amount of compensation on your behalf.

Reasons for Workers’ Compensation Denials

Reasons for Workers' Compensation Denials

Before you can appeal an adverse workers’ compensation decision, you must understand why the insurer made the denial decision in the first place. You should not have to look hard for the reason, as insurers have a duty to provide a rationale for everything they do, from delaying investigations to issuing denials. Failure to explain the reason(s) for your denial may be deemed an act of bad faith.

Regardless of legitimacy, insurers will almost always issue a letter that cites one or several reasons for denying claims. The most common reasons cited on said letters are as follows:

  • Failure To Comply With Reporting Requirements: When you sustain an on-the-job injury, you should notify your employer right away. However, the law grants you up to 30 days to file a report. Though not complete grounds for denial, failure to submit a written report within a month of your injury can result in an adverse decision.
  • Presence of Drugs or Alcohol in Your System: If your post-injury medical evaluation reveals that you had drugs or alcohol in your system at the time of the accident, you may forfeit your rights to benefits. This may be the case even if the drugs in your system are a type of medication. If you take prescription medications, you should keep a doctor’s note handy at all times.
  • Suspicion of Self-Inflicted Harm: Workers’ compensation benefits insurers are not required to issue payments for self-inflicted injuries. If you intentionally harm yourself at work or while engaging in work-related activities, not only will you not receive benefits but also, the insurer may charge you with fraud. A fraud conviction may bar you from recovering benefits for legitimate injuries in the future.
  • Unidentifiable Cause: Unfortunately, if a medical examiner cannot verify that your injuries occurred as a result of your work related activities, the insurer may deny your claim. In these cases, it is helpful to have witness testimony and/or video evidence. If you are unsure if video evidence exists, your workers’ compensation attorney can look into the issue on your behalf.
  • Lack of Witnesses: Building off the above point, if you cannot identify any witnesses who can validate your claim, you may struggle to prove that your accident occurred as you said it did. More importantly, you may struggle to prove that it occurred at your place of work or during work hours at all.
  • Lack of Severity of Injury: The severity of your injury — or lack thereof — in and of itself is not grounds for a workers’ comp denial. The law entitles all injured workers to benefits, even if the value of those benefits adds up to a couple days’ worth of wages.

That said if you claim that your injury is more severe than it is, and if the medical examination reveals this, the insurer may consider your actions fraudulent. It has the right to deny all fraudulent claims.

  • Non-Work-Related Injury: If a medical examination reveals that your injuries are not work-related or that you sustained them after filing your initial claim and while engaging in activities that have nothing to do with your job, the insurer may deny your claim.
  • Failure To Continue Medical Treatment: If your doctor gave you orders to go through a treatment program and you ignore those orders, the workers’ comp insurer has the right to discontinue your benefits. It is your responsibility to continue to seek treatment for your injuries until your doctor gives you the go-ahead to return to work.
  • Disputes Over Employment Status: Disputes over employment status are increasingly common in today’s gig economy. Your employer may try to claim that you are technically an independent contractor, self-employed contractor, freelance worker or otherwise a non-employee. Of course, your employer must have substantial documentation to prove this assertion. 

If your workers’ comp is denied for one or several of the aforementioned reasons, our NYC workers’ compensation attorneys can assess the evidence and take steps to secure you a favorable decision. However, it is important that you act quickly, as you have two years from the date of your injury (or discovery of your injury) to pursue a claim.

Will You Receive Benefits If the Insurer Denies Your Claim?

Will You Receive Benefits If the Insurer Denies Your Claim

Unfortunately, if you must take time off from work due to your injury but the insurance company denies your claim regardless, you will not receive any benefits while your case awaits a hearing or trial.

In such a situation, you have a few options for covering your medical expenses and costs of living:

  • Many medical offices that accept Workers’ Compensationensation insurance will continue to treat you while your claim in pending.
  • Dip into your savings.
  • Take out a personal loan.
  • Look into pre-lawsuit settlements.

Discuss each option with your workers’ comp lawyer to determine which makes the most sense for your situation. It may comfort you to know that, if your claim is successful, the insurance company will have to backdate your weekly benefits to the date of your injury. 

Steps for Resolving a Workers’ Compensation Dispute

Steps for Resolving a Workers’ Compensation Dispute

Now that you understand why insurers deny workers’ compensation claims and what it means for you, it is time to explore your options for fighting the decision. The New York Workers’ Compensationensation Board has established a process by which employees, employers and insurers can resolve their disputes. The process includes several stages, which you must navigate through if you continue to receive denials.

At each level, you must file the appropriate paperwork in a timely fashion. You must also submit supporting evidence and follow correct legal procedures. To ensure you do not make mistakes at the appeals stage, contact a workers’ compensation law firm to consult with a workers’ comp lawyer.

The Pre-Hearing Conference

If an insurer plans to deny your workers’ comp claim, it must file a “notice of controversy” with the Workers’ Compensationensation Board. It must do so within 25 days of receiving your claim. Once the board receives the notice, it will schedule your pre-hearing conference. Once scheduled, you have a responsibility to submit appropriate documentation and evidence, including a Pre-Hearing Conference Statement.

The board may not make any decision that pertains to your benefits at the pre-hearing conference. Rather, the administrative law judge uses the process to streamline everything that comes next. That may include resolving issues that could affect the final hearing, deciding on issues that the judge at the formal hearing will review, determining whether you require an independent medical examination and gaining access to your medical records. The ALJ may also decide to postpone your formal hearing, or even schedule a trial date.

The Formal Hearing

The formal hearing is the hearing in which you and the insurance company will present your cases. Both you and your attorney, the insurer and its attorney, and the ALJ will be present at this hearing. Your employer may also decide to send a representative.

During the hearing, either side may call on witnesses, such as coworkers, and experts, such as medical professionals and other relevant persons. Either party may also submit evidence, which may include photos, videos, employment records, medical records, bills, paystubs, the results from impairment screenings and the like.

The judge will use both the testimony given and the evidence presented to make a determination regarding benefits. The judge also has the power to resolve substantive issues regarding the claim itself, such as your disability status, impairment rate, the compensability of your injury, and your average weekly wages.

Judges at this stage of the claims process do not make decisions hastily. However, if the judge affirms the insurer’s denial of benefits, and if you feel as if he or she was wrong to do so, you have the option to appeal. Likewise, if the insurer disagrees with a decision in your favor, it can appeal via the same process.

Appealing a Workers’ Comp Denial

Appealing a Workers' Comp Denial

If you are unhappy with the decision you received during the formal hearing, you have the right to file an appeal. There are three levels at which you may appeal a workers’ comp decision in New York: at the board level, with the Appellate Division and with the Court of Appeals.

Review by the Workers’ Compensation Board

If the judge who presides over your formal hearing denies rules in the insurer’s favor, you have 30 days from the date of the filing of the decision to petition for a review by the Workers’ Compensationensation Board. To submit a request for review, you must fill out and submit a formal application, to which your workers’ comp lawyer can assist you with. 

Appeal to the Appellate Division

If the panel or the board affirms the denial — or if it denies your claim after the insurer appealed — your next step would be to take up your case with the Appellate Division. To do so, you must, again, file a Notice of Appeal. You must file the notice within 30 days of receiving the board’s decision. As the decision-makers before did, the appellate court will consider the evidence associated with your claim, witness testimony and any other relevant information before making a decision.

Appeal to the Court of Appeals

Finally, if you still have yet to receive an affirmative decision, you can request a review from the state’s highest court: The New York Court of Appeals. It is unusual for appeals to make it to this level, and the courts typically only hear them if they involve unsettled questions or unusual concerns associated with workers’ compensation law.

The Benefits of Hiring Workers’ Comp Lawyers

The Benefits of Hiring Workers' Comp Lawyers

There are several reasons that injured workers hire workers’ compensation law firms to help with their cases. The most common reasons for doing so are as follows:

  • They want to ensure they file their claims correctly.
  • They do not understand the claims process.
  • They believe that legal professionals can help them build better cases than they could do on their own.
  • They want to make sure that the medical bills are paid for on-the-job injuries.
  • They have an attorney assign them with hearings, trials, depositions, and appeals.

These are all very good and valid reasons to retain the help of an attorney from day one. In fact, by hiring an attorney long before an insurer has the chance to deny your claim, you can substantially increase your odds of approval and possibly avoid the lengthy appeals process entirely. If you are still not sold on the benefits of working with a skilled workers’ compensation lawyer, consider the following.

Get Support and Guidance From Day One

Though states devise their workers’ comp laws for the benefit of workers, the laws are often confusing and complex. As a result, many injured persons do not understand their rights or responsibilities under them. Workers’ comp attorneys, on the other hand, do. A knowledgeable lawyer can inform you of what you need to do to comply with state laws. He or she can also help you navigate the claims process, ensure you meet filing deadlines and, when necessary, meet with insurers on your behalf.

Get Help Building Your Case

A savvy lawyer will not just protect your rights to benefits. He or she will also look for additional ways you can recover under the law. For instance, an attorney might review your claim and also recommend that you file for social security benefits or even a wage and hour claim. Your lawyer can also advise you on the types of evidence and documentation you may need to build a robust case.

Get an Accurate Estimate of the Value of Your Case

The right workers’ comp attorney can review the facts of your case and come up with a ballpark figure of how much in benefits you may receive. Though this figure is likely to change, a skilled lawyer will consider your medical condition, lost wages and other damages to estimate a sum that is, if not 100% accurate, close to it.

Retain the Help of an Experienced Workers’ Comp Lawyer in New York City

New York devised its workers’ compensation laws to make recovering benefits as easy and cost-effective for injured parties as possible. Despite this, insurers continue to deny claims on a frequent basis, thereby negating the whole purpose of the workers’ comp system. If a denial happens to you, you may become frustrated. However, do not give up.

Hire a workers’ compensation law firm in New York that has a long-standing reputation for helping injured employees recover the benefits they need and deserve. Contact Pyrros & Serres, LLP, today to schedule your free consultation.


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About The Author

Picture of Michael Serres, ESQ.

Michael Serres, ESQ.

Michael Serres, ESQ. is a reputed Workers’ Compensation Lawyer in Astoria, Queens, NY. He graduated from St. John’s University School of Law in 1989. Mr. Serres was admitted to practice law in New York State in 1990 and is admitted in the Federal District Courts for the Southern and the Eastern Districts of New York. He has served on the Board of Directors of the Workers’ Compensation Bar Association and is currently serving on the Board of Directors of the Queens County Bar Association.