What to Do if Your Workers’ Comp Claim is Denied in NY

Facing a denial of a workers’ compensation claim can be a frustrating and overwhelming experience, especially when you are relying on those benefits to help you recover from a work-related injury. In New York, the workers’ compensation system is designed to provide financial relief for medical expenses and lost wages if an employee is injured on the job. However, claim denials are not uncommon, and they can happen for various reasons. If your workers’ comp claim is denied in New York, it is essential to understand your options and take the necessary steps to appeal the decision.

This guide will provide a detailed explanation of what you should do if your workers’ comp claim is denied, including the reasons why claims may be rejected and how to navigate the appeals process in New York. Cole, Sorrentino, Hurley, Hewner & Gambino, P.C. provides dedicated support and guidance to individuals navigating the complexities of workers’ compensation claims after an accident.

Understanding Why Your Workers’ Comp Claim Was Denied

The first step in dealing with a denied workers’ comp claim is to understand the reasons behind the denial. There are numerous factors that could lead to a rejection of your claim, and knowing why your claim was turned down will help you take the appropriate actions moving forward.

One of the most common reasons for a denial is insufficient medical documentation. In New York, a successful workers’ comp claim must be supported by detailed medical records that clearly establish the nature and extent of your injury. If your medical records are incomplete or do not demonstrate a direct connection between your injury and your job, the insurance company may deny your claim.

Another reason could be a dispute about whether your injury was work-related. Sometimes, an employer or insurance company might argue that the injury occurred outside of work or was caused by pre-existing conditions rather than a workplace accident. If there is any uncertainty about how and when the injury occurred, the insurance company may refuse to pay out workers’ comp benefits.

Your claim might also be denied if it was not filed within the required timeframe. In New York, there are strict deadlines for reporting an injury to your employer and for filing a workers’ comp claim. If you fail to meet these deadlines, your claim could be rejected. It is crucial to report your injury to your employer as soon as possible and to ensure that all necessary paperwork is filed in a timely manner.

Lastly, insurance companies may deny claims based on procedural issues or missing information in the initial filing. Something as simple as incomplete paperwork or a missing signature could lead to a denial, even if you are otherwise eligible for benefits.

Steps to Take After Your Workers’ Comp Claim is Denied

Once you understand the reason for the denial, the next step is to take action. While a denial can feel like a setback, it is important to know that you have the right to appeal the decision. In New York, the workers’ compensation appeals process allows injured workers to challenge a denial and present additional evidence to support their claim.

The first thing you should do after a denial is to request a written explanation from the insurance company. This document, called a denial notice, will explain why your claim was denied and provide important information about your rights to appeal. Make sure to review this document carefully, as it will help guide your next steps.

After receiving the denial notice, you should immediately consult with a workers’ compensation attorney. Workers’ comp law in New York can be complex, and having an experienced legal professional on your side will greatly increase your chances of successfully appealing the denial. A lawyer can help you gather additional evidence, including medical records and witness testimony, to strengthen your case.

Your attorney will guide you through the process of requesting a hearing with the New York Workers’ Compensation Board. At this hearing, you will have the opportunity to present your case before a judge who will review the evidence and make a determination about whether you are entitled to benefits. The hearing is your chance to correct any mistakes or misunderstandings that may have led to the denial and to provide the necessary documentation to support your claim.

Related Videos

Gathering Additional Evidence for Your Appeal

One of the most important aspects of appealing a denied workers’ comp claim is gathering additional evidence to support your case. If your initial claim was denied due to lack of medical documentation, you will need to work with your doctor to obtain detailed records that clearly explain your injury and its connection to your job. This might include diagnostic tests, medical reports, and opinions from your healthcare provider.

In some cases, you may also need to obtain testimony from coworkers or other witnesses who can corroborate your version of events. For example, if your employer or the insurance company disputes that the injury occurred at work, witness statements from people who saw the accident happen can be invaluable.

It is also important to keep thorough records of any communication with your employer, the insurance company, and medical providers. Documenting all interactions can help you demonstrate that you followed the proper procedures and reported your injury in a timely manner.

If your claim was denied due to a procedural error or missing paperwork, your attorney can help you correct these issues and ensure that your appeal is properly filed. The appeals process in New York is time-sensitive, so it is critical to act quickly and follow all required steps.

The Role of the Workers’ Compensation Board Hearing

After gathering the necessary evidence, your next step is to prepare for the hearing before the Workers’ Compensation Board. This hearing is a formal proceeding in which both you and the insurance company will present your arguments and evidence to a judge. The judge will review all of the information and issue a decision about whether to uphold the denial or award you benefits.

At the hearing, it is essential to present a compelling case supported by strong evidence. This may include testimony from medical professionals, witnesses to the accident, and detailed medical documentation. Your attorney will play a key role in presenting your case and advocating for your rights.

The hearing process can be lengthy, and it is not uncommon for multiple hearings to be required before a final decision is made. Throughout this process, your attorney will work to ensure that your rights are protected and that you have the best possible chance of obtaining the benefits you deserve.

Appealing an Unfavorable Decision

If the judge rules against you at the hearing, you still have options. In New York, you can appeal the decision to the Workers’ Compensation Board’s Appeal Panel. This panel will review the hearing judge’s decision and the evidence presented at the hearing. If the Appeal Panel also rules against you, you can take your case to the New York State Appellate Division.

Each level of appeal involves additional legal procedures and requirements, so it is crucial to have an attorney who understands the nuances of New York workers’ compensation law and can effectively represent your interests at each stage of the process.

What to Expect After a Successful Appeal

If your appeal is successful and the denial is overturned, you will be entitled to receive workers’ compensation benefits. These benefits may include coverage for medical expenses related to your injury, compensation for lost wages, and rehabilitation services if necessary. The exact amount and duration of your benefits will depend on the severity of your injury and your ability to return to work.

It is important to note that even after winning an appeal, you may encounter challenges in receiving your benefits. Insurance companies sometimes delay payments or attempt to reduce the amount of compensation awarded. If this happens, your attorney can help you enforce the decision and ensure that you receive the full benefits to which you are entitled.

Preventing Future Workers’ Comp Claim Denials

While some claim denials are unavoidable, there are steps you can take to reduce the risk of having your workers’ comp claim denied in the first place. One of the most important things you can do is to report your injury to your employer as soon as it happens. New York law requires that workplace injuries be reported within 30 days, so it is critical to act quickly to preserve your right to file a claim.

You should also seek medical attention immediately after the injury occurs. Not only is this important for your health and recovery, but it will also provide you with the medical documentation needed to support your workers’ comp claim. Be sure to follow your doctor’s recommendations and attend all scheduled appointments, as this will demonstrate that you are actively working to recover from your injury.

In addition, it is crucial to file your workers’ comp claim promptly and ensure that all necessary forms are completed accurately. Any errors or omissions in the paperwork could lead to a denial, so it is important to double-check everything before submitting your claim.

If your workers’ compensation claim has been denied, do not give up. You have the right to appeal the decision, and with the right legal representation, you can increase your chances of success. The attorneys at Cole, Sorrentino, Hurley, Hewner & Gambino, P.C. are experienced in handling workers’ compensation cases in New York and can help guide you through the appeals process. Contact us today for a consultation and let us fight for the benefits you deserve.