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The Legal Process if a Workers’ Compensation Claim Is Denied

Offered by Pasternack, Tilker, Ziegler, Walsh, Stanton & Romano LLP

Workplace accidents happen frequently in New York City, and can have a devastating impact on injured workers. They need medical treatment, and it may take weeks or months for them to fully recover from their injuries. In the meantime, they may be unable to work and there is less income coming in.

In New York, workers who suffered a job-related injury or illness can file a workers’ compensation claim. They are eligible for benefits that include coverage of all medical expenses related to the injury or illness, partial replacement of lost wages if they can’t work for an extended period, and in some cases, disability payments.

But many initial claims for benefits are denied. Here are some reasons why:

  • Missed deadlines – In order to be eligible for benefits, you must provide written notification of your injury or illness to your employer within 30 days. A claim for benefits must be filed within two years of the date of your injury or from the time you learned an illness was job-related.
  • Disputes over whether an injury or illness was work-related – An employer or insurance company may dispute whether an accident truly happened at work or an illness was truly caused by conditions in the workplace.
  • Lack of medical documentation – When filing a claim for benefits, documentation that proves an injury was suffered needs to be provided. Types of medical documentation include a doctor’s treatment notes or copies of medical records.
  • Problems with paperwork – Certain forms need to be properly filed to apply for benefits.
  • The injury was intentional – Claims may be denied when workers intentionally injure themselves. This also includes injuries in a fight you started.
  • An injured worker did not seek immediate medical attention – Symptoms of some workplace injuries may not appear for days or even weeks. If the worker doesn’t see a doctor right away, employers and insurance carriers will say this is evidence the injury was not suffered at work.
  • There were no witnesses – If no one witnessed the injury, that creates uncertainty that the insurance company can exploit.
  • Disputes over employment status – An employer may try to argue that an injured worker is an independent contractor and therefore not eligible to receive workers’ compensation benefits.

Employers and insurance carriers may deny an injured worker’s claim for one of these reasons. However, a denial of an initial claim for benefits is not final. Workers have access to a hearing process to resolve disputes and an appeals process to challenge an adverse decision.

The initial process to resolve workers’ compensation disputes

If the insurance company denies workers’ compensation benefits or denies payment for a particular portion of the claim, there is an established process that allows workers to challenge the decision. At each step, the correct paperwork must be filed, supporting evidence must be provided and proper procedure must be followed. The process can begin soon after an initial claim for benefits is denied.

Note that at any stage in the process, a lawyer may also be able to resolve your claim by negotiating a settlement with the insurance company.

Pre-Hearing Conference

If an insurance carrier plans to deny your claim or a portion of your claim, they can file a “notice of controversy” with the Workers’ Compensation Board. This must be filed within 25 days of receiving the claim. Then, a pre-hearing conference will be scheduled. Certain paperwork must be submitted at this stage, including a Pre-Hearing Conference Statement.

The pre-hearing conference is essentially an informal preliminary hearing in which an administrative law judge (ALJ) can resolve matters that will affect the formal hearing. For instance, the ALJ may decide disputes regarding the list of issues that are to be reviewed at the formal hearing, access to medical records, or whether you need to undergo an independent medical exam (IME). The judge can also decide whether to postpone the formal hearing. Disputes regarding the claim itself, such as the amount of benefits you will receive, are not decided at the pre-hearing conference.

Formal Hearing

The formal hearing is an opportunity for both sides (that is, the injured worker and the workers’ comp insurance company) to present their case. The injured worker, their lawyer, the insurance company’s lawyer, and the ALJ are always present at this hearing. The employer may also send a representative.

During the conference, both sides will be allowed to present their case. Witnesses may be called, including coworkers who witnessed the accident as well as doctors and other relevant experts. Evidence must be submitted, including medical records, impairment assessments, bills, paystubs, employment records and so on.

Based on the testimony, the judge will issue a decision regarding the amount of benefits you will receive and for how long. Formal hearings can be used to resolve any substantive dispute about the claim itself, such as your impairment rating, disability status, average weekly wages, and whether a particular injury or illness is compensable.

If you disagree with the judge’s decision, you have the option to appeal. Likewise, if the insurance company disagrees with the decision, they can appeal via the same process.

The workers’ compensation appeals process in New York

There are potentially three levels where you can appeal a workers’ compensation decision in New York: the Workers’ Compensation Board, the Appellate Division, and the Court of Appeals.

Review by the Workers’ Compensation Board

If a judge rules against your claim, you have 30 days from the date of the ruling to request a review by the Workers’ Compensation Board. This request can be made by submitting an Application for Board Review. A panel consisting of three board members will then decide whether to review the decision. If your request is granted, the judge’s decision will be reviewed.

There is no time limit on how long a review will take. The three-member panel will ultimately either affirm the judge’s decision, modify the decision, or rescind it. In some cases, they may send the claim back to the judge for further consideration. If the three-member panel cannot come to a unanimous decision, then either the injured worker or the insurer can request a review by the full Board.

Appeal to the Appellate Division

If your claim is still denied, you can file a notice of appeal with the Appellate Division, Third Department, Supreme Court of the State of New York. An appeal must be filed within 30 days of the board’s decision. The court will consider evidence presented by both sides as well as witness testimony before issuing a ruling.

Appeal to the Court of Appeals

If the Appellate Division upholds the denial of benefits, you can seek a review of your case from the New York Court of Appeals, the state’s highest court. Note that appeals at this level are quite rare. The court usually only considers cases involving an unusual or unsettled question of workers’ compensation law.

Navigate the workers’ compensation process with an experienced attorney

Because the legal process can be complicated, it is important for injured workers to be represented by an experienced New York workers’ compensation attorney. A lawyer can ensure all paperwork is filled out correctly and filed on time, gather medical evidence proving you were injured and represent you at all hearings.

If you were injured on the job or suffered a work-related illness in New York City, it’s important to get advice from an experienced workers’ compensation lawyer. Schedule a free consultation today.

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