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Steps To Take If Denied Workers’ Comp In New York

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Suffering an injury at work and having trouble getting the benefits you deserve?

Let an experienced New York workers’ compensation lawyer fight for you!

New York workers' compensation laws are designed to offer financial support during your recovery. However, the process of securing these benefits isn't always straightforward. Being denied workers’ comp can be a significant setback, but it's not always the final outcome. 

Workers' compensation operates on a no-fault basis and promises benefits without needing to prove fault. Despite this system, denials are common. With experienced legal assistance, the chances of overturning a denial may improve significantly. Contact a New York workers’ comp attorney and schedule a free consultation.

Below, you’ll find key steps to take if you’re denied workers’ comp in New York.

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The insurance company that issues workers’ compensation benefits is required to provide a detailed explanation for denying your claim. Understanding the reasons behind a denial is crucial before appealing the insurance company’s decision. 

Common reasons for denial include: 

  • Not reporting the injury to your employer within the mandated 30-day period.
  • Missing the two-year deadline on filing your claim. 
  • Failure to seek medical attention. 
  • Testing positive for drugs or alcohol.
  • Suspicions of self-inflicted harm.
  • Inability to prove the injury is work-related due to lack of evidence or witnesses. 
  • Questions regarding the injury's severity.

If you’re denied workers’ comp in New York or you disagree with the decision, you can file an appeal with the New York State Workers' Compensation Board. This must be done within 30 days after receiving your denial.

To file an appeal, you must use the current Application for Board Review (Form RB-89). This form must be filled out entirely, and a legal brief may be attached to support the appeal.  Incomplete applications may delay the appeals process. 

You must clearly detail the case and claim numbers, parties involved, injury date, issues for review, and the basis for the appeal. Plus, you should include any new evidence and objections raised during hearings. Appeals should argue your case, with legal briefs capped at eight pages unless a valid reason is provided.

Step #3: Prepare for the appeal hearing

Your case will be scheduled for a hearing before the New York Workers’ Compensation Board. Gather all relevant documentation, such as medical records, witness statements, and any evidence that supports your claim and refutes the reasons for the denial.

This may involve getting detailed reports from your treating physicians or specialists that outline the extent of your injury, the treatments you have undergone, their necessity, and the causal relationship between your work and your injury.

Also, be ready to clearly and concisely explain your case, how your injury occurred, the impact of your injury on your life and work, and why you believe the initial decision was incorrect.
It helps to practice your testimony in advance to ensure you can present your case confidently and coherently.

Be prepared for the possibility that the board may uphold the original decision, modify it, or remand the case for a new hearing. Understand your options for further appeals if necessary.

At the hearing, present your case with the assistance of your attorney. This is your opportunity to provide testimony, present evidence, and have witnesses speak on your behalf.

Should an insurance company intend to reject your workers' compensation claim, it’s required to submit a "notice of controversy" to the Workers' Compensation Board no later than 25 days after your claim is filed. Upon receipt of this notice, the board will organize a pre-hearing conference. It is your duty to provide all necessary documents and evidence for this conference, including a Pre-Hearing Conference Statement.

No decisions regarding your benefits will be made at the pre-hearing conference. Instead, this step is designed by the administrative law judge to prepare for subsequent proceedings. This preparation may involve: 

  • Addressing potential issues.
  • Deciding on matters for review at the formal hearing.
  • Evaluating the need for an independent medical examination.
  • Accessing your medical records. 

Additionally, the judge has the authority to either delay your formal hearing or set a date for a trial.

At the formal hearing, both you and the insurance company will argue your cases before the administrative law judge, accompanied by your respective attorneys. Your employer might also send a representative to participate.

This stage allows both parties to present witnesses, including coworkers and medical experts. It also allows you to submit various forms of evidence such as photographs, video recordings, employment and medical records, bills, pay stubs, and results from impairment assessments.

Step #5: Await the judge's decision

After the hearing, the judge will issue a decision regarding your appeal. This may grant you the benefits, deny your appeal, or request further information.

Decisions at this phase are made with careful consideration. They aim for a fair outcome based on the presented facts. Should the judge uphold the denial of your benefits and you disagree with the ruling, or if the insurance company contests a decision favorable to you, either party may initiate an appeal. This would continue the legal process to seek a revised judgment.

This appeals process ensures multiple opportunities to contest an unfavorable decision. It provides a pathway to potentially overturn the initial ruling and secure the compensation you believe is justly owed.

If the judge's decision is unfavorable, you can appeal to a three-member panel of the Workers' Compensation Board. Should you find the outcome of your formal hearing unsatisfactory, New York law permits you to appeal the decision across three hierarchical levels: 

  • Workers' Compensation Board Review: If the decision from your formal hearing is not in your favor, you have a 30-day window from the decision's issuance to request a review by the Workers' Compensation Board. A detailed application for review must be completed and submitted.
  • Appellate Division Appeal: Should the Board uphold the initial denial or if it rejects your claim following an appeal by the insurer, the next recourse is the Appellate Division. A Notice of Appeal must be filed within 30 days of the Board's decision. The Appellate Division will then reassess your claim, examining the evidence, witness accounts, and other pertinent details before rendering a verdict.
  • Court of Appeals: If the outcome remains unfavorable after the Appellate Division's review, you may seek further appeal to the New York Court of Appeals, which is the state's supreme judicial authority. Appeals at this level are rare and are reserved for cases posing significant legal questions or unique concerns regarding workers' compensation law.

Hiring an experienced New York workers’ compensation lawyer can make a night-and-day difference in the outcome of your case. They can help you ensure accurate claim filing, navigate the claims process, construct stronger cases, and secure coverage for medical expenses. Plus, they offer representation in hearings and appeals.

Beyond safeguarding benefit rights, a lawyer can explore additional legal avenues for compensation, such as social security or wage and hour claims. Additionally, an experienced lawyer can provide a realistic estimate of the potential benefits based on your medical condition and lost wages.

If denied workers’ comp in New York, working with an experienced lawyer can be a decisive step towards overcoming obstacles and securing the benefits you deserve. Don’t navigate the process alone. Schedule a free consultation with a New York workers’ compensation attorney today.

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