By John Arthur 
Workers’ comp denial letters are frustrating.
You were injured on the job. You did everything right. And now you’re getting slammed with a denial letter from the insurance company.
But here’s something employees don’t realize…
A denial isn’t the end of the process.
Workplace injury benefits are a legal right — and there are several options available to help you fight the insurance company that most workers don’t know about. The insurance company is banking on hurt employees throwing their hands up and giving up. Don’t let them.
Let’s review your options.
In this article you’ll learn
- Why Workers’ Comp Claims Are Denied
- Legal Options You Have With A Denied Claim
- How To File An Appeal On A Denied Claim
- When You Should Hire An Attorney
- Mistakes To Avoid With A Denied Claim
Why Workers’ Comp Claims Are Denied
If you’re starting here, you might be wondering why workers’ comp claims even get denied in the first place.
That’s actually a great question. Insurance companies don’t have a great track record of being helpful.
Workers’ comp claims can be denied for any number of reasons:
- You didn’t report the injury soon enough
- Your employer contests that it happened at work
- You don’t have enough medical evidence
- They’re using a pre-existing condition to deny you
- Mistakes were made on forms or deadlines were missed
Here’s the frustrating reality. A lot of those reasons can be fixed. Approximately 7% of workers comp claims are denied each year. That’s 343,000 Americans that are suddenly left trying to figure out what to do after their claim was denied and not sure where to turn.
Those numbers have also been on the rise. Recent data indicates that the nationwide average claim denial rate increased from 13.42% (2010–2019) to 14.97% (2020–2024) — a jump of over 11%.
The game isn’t getting easier. But the options for workers still are.
Legal Options You Have With A Denied Claim
Alright, now let’s dive into the good stuff.
When most workers get denied they assume the process is over. It’s far from over.
Each employee has options when dealing with a denied claim — you just might not know about them.
File An Appeal
Did you know you automatically get the right to appeal any workers’ comp denial?
It’s true. Every state has an appeals process attached to their workers’ compensation program. If you get denied, you can file for an appeal to have your claim heard in front of a workers’ compensation judge.
An appeal is a legal process. Having legal counsel such as a workers comp attorney in Fresno review your situation before filing could make all the difference in your workers’ compensation case.
Request An Independent Medical Exam
Want to know a secret?
Insurance companies are in the business of saving money — not paying out claims.
When they deny a claim based on a medical reason, like “your injury wasn’t caused by work”, you can call for an independent medical exam.
An independent medical exam means you get a neutral doctor to review your injury and give their opinion on the matter. Hopefully, their opinion does not match the insurer’s and you’re left with proof to dispute the denial during an appeal.
File A Bad Faith Claim Against Your Insurer
Insurance companies have to act in good faith. If they didn’t properly investigate your claim or purposely delayed the process, you can fight back with a bad faith insurance claim against the insurance company itself.
You can do this in addition to appealing the workers’ comp denial. Bad faith claims have the potential to unlock additional damages not covered by workers’ comp.
Sue A Third Party
Workers’ comp is designed to prevent you from suing your employer.
But that doesn’t mean there aren’t other options.
If your injury was caused by someone else – whether it be faulty equipment, another negligent worker or unsafe property conditions – you may be able to sue that third party for pain and suffering on top of your workers’ comp claim. This is known as a third-party claim.
How To Appeal A Denied Workers’ Comp Claim
Appealing a claim isn’t as scary as it sounds. Let’s walk through the basic process.
- Review your denial letter. Understand specifically why they denied your claim
- Build your evidence. Compile medical records, incident reports, witness testimony, etc.
- File the appeal. Don’t forget this deadline or you can lose your right to appeal
- Go to the hearing. You’ll present your case in front of a judge
- Comply with all orders. Once a decision is reached you’ll need to follow up
Remember…
Appeals have a deadline. Don’t blow past that date or you could lose your ability to appeal the workers’ comp denial.
When You Should Hire An Attorney
Don’t try to fight your denial alone.
It’s already an uphill battle for workers. Letting the insurance company take advantage because you don’t know workers’ comp law won’t do you any favors.
Insurance companies have legal teams that fight workers’ comp claims every day. They know how to minimise what they pay out. Attorneys specialising in workers’ comp know how to fight back. Don’t let the insurance company roll over you.
Here are a couple reasons you should hire a lawyer.
- A knowledgeable attorney will know how to position your appeal
- They’ll know what evidence will help (or hurt) your case
- Lawyers can negotiate with the insurance company on your behalf
- Your attorney will represent you at your appeal hearing
Oh, and here’s some data for you too.
Risk & Insurance crunched the numbers and found that 70.6% of denied claims that went to litigation were paid. That’s compared to only 27.5% of non-denied claims that required litigation. Fight.
Mistakes To Avoid After Your Claim Is Denied
Essentially, once you receive a denial you can win or lose your claim based on the next steps you take. Here are some of the biggest mistakes that workers make during this process:
- Missing the deadline to appeal your claim
- Failing to see a doctor right away
- Giving a recorded statement without speaking to an attorney
- Taking the first settlement offer
- Representing yourself during the appeals process
Make sure you avoid these common workers’ comp pitfalls.
The Bottom Line
Don’t take a workers’ comp denial as your final verdict.
Workers deserve to be compensated for workplace injuries. If you feel that your claim was wrongfully denied there are plenty of options to hold the insurance company accountable. File an appeal. Gather your evidence. Or consult with a workers’ comp attorney to learn about your options.
As long as you know those options exist.
Time To Take Action
A denial is not an end-all be-all decision. It’s simply time to learn more and fight for what you deserve.
Here’s your action plan once you’ve been denied:
- Learn why your claim was denied
- Understand what legal options you have
- File an appeal (before the deadline)
- Explore all your options, not just an appeal
- Consult with a lawyer before making any big decisions
Remember, the system is set up to make this process as confusing and difficult as possible.
But workers win denied claims every day. Don’t be a statistic.