What if My Workers’ Compensation Claim Is Denied?

What if My Workers’ Compensation Claim Is Denied?

The first step to take after your workers’ comp is denied is to determine the denial reason. You can find this reason in the denial letter. Employers and their insurance companies may deny claims for various reasons, including lack of an employment relationship, late reporting, failure to obtain medical help, incomplete or inaccurate documentation, and pre-existing conditions. You may appeal the decision if the denial decision is unjustified.

Worker compensation claim with a stamp denied workers' comp denied.

Experienced workers’ compensation lawyers know the common reasons Illinois employers and insurers deny claims. They also understand workers’ comp laws. Such lawyers can explain your rights, determine the merits of your case, and offer personalized support during the appeals process. You have a higher chance of getting the denial decision reversed with a lawyer in your corner than when representing yourself.

Workers’ compensation lawyers at Martay Law Office can help you successfully appeal a denied claim and receive your benefits. Call 312-374-6403 to request a free consultation.

What Are the Most Common Reasons for Denial?

A 2021 report shows that 8% of workers’ comp cases filed in Illinois in 2020 were dismissed. The same report shows that the percentage dropped to 2% in 2021. The most common reasons for workers’ comp denial include:

Lack of Employment Relationship

You must have an employment relationship with your employer to be entitled to workers’ compensation benefits. Most independent contractors are exempted from workers’ compensation coverage. Employers may, however, misrepresent an employee as an independent contractor to justify workers’ compensation denial.

Late Reporting and Missing Crucial Deadlines

Workers have fixed deadlines for reporting job-related injuries to their employers or supervisors. Illinois sets that deadline at 45 days from when your injury happened. Your claim may get denied if you file past the reporting deadline.

Filing a claim after the statute of limitations has elapsed can also result in a denial. The timeline for filing a workers’ comp case in Illinois is within 3 years from the workplace accident date or 2 years from your last benefits, whichever occurs later.

Failure to Seek Adequate Medical Assistance

Medical assessments of your injury are mandatory in the workers’ comp claim process. Insurance companies can deny your claim if you ignore or fail to seek medical help. They can also do the same if a doctor recommended by your employer issues a negative report. That is why you should go to your own doctor for workers’ comp to ensure you get the right treatment and accurate representation of your injuries.

The insurance company may also deny your claim if you return to work too soon after a workers’ comp injury. The company may accuse you of exaggerating your injuries or even claim you did not sustain any injury in the workplace accident or incident.

Pre-Existing Conditions

You qualify for benefits if a work-related injury exacerbates an underlying injury or condition. Likewise, you can receive benefits if you sustain a repetitive use injury because of job activities that require you to do the same range of motion repeatedly.

An insurance company may cite your pre-existing injury or condition as justification for denying your claim. The company may argue that you are pursuing benefits for a health issue that existed even before the alleged workplace accident.

Your Injury Is Not Job-Related

Your employer or the insurer may deny your claim if your injury occurred when you were outside the work zone. Exceptions apply to this rule. For instance, you may be entitled to benefits if injured while performing a special task for your employer outside the work zone.

Positive Drug Test

Your employer may require you to undergo a drug test after you report a work-related injury. A positive drug test may lead to a claim denial. A positive result, however, is not sufficient to bar you from receiving benefits. Illinois workers’ comp laws offer a rebuttable presumption, allowing you to provide proof to challenge the assumption that you were under the influence of drugs when you sustained a workplace injury.

Incomplete Reporting or Documentation

Your employer may deny your claim by alleging that you failed to provide sufficient information about the incident. The insurer, on the other hand, may cite missing documents or incorrectly filed paperwork to justify the denial decision. So, insufficient reporting or documentation is one of the mistakes to avoid when filing a workers’ comp claim.

Steps to Take if Your Claim Is Denied

A denial does not mark the end of your workers’ compensation claim. Illinois laws allow you to appeal the decision, especially if you can demonstrate that it was reached erroneously. Take the following steps to maximize the odds of a successful appeal:

Determine the Denial Reason(s)

Start by determining the reason for your claim denial. You can find these reasons outlined in the denial letter. So, carefully read the letter, identify the reasons, and try to understand the facts and arguments justifying the denial decision.

Keep an Open line of Communication With Your Employer

A claim denial may stem from miscommunication or administrative errors. Meeting the employer to discuss the matter may sometimes be enough to reach a resolution. You may also get new information or documentation to strengthen your appeal.

Collect Additional Evidence

Collect additional evidence to disprove reasons and arguments provided by the insurance company to justify turning down your claim. This collection may involve obtaining doctor’s notes, diagnostic reports, and other relevant medical documentation linking your injury or condition to your work-related tasks or workplace hazards. It may also involve compiling statements from colleagues who were present at the accident or incident scene and are willing to testify in your favor.

File an Appeal

You may have a valid legal basis to appeal a workers’ comp claim denied in Illinois. You can start the appeal process by contesting the denial decision directly with the insurer. You can do that by submitting a detailed appeal letter and supporting evidence to the insurer.

If the insurance company declines to reconsider its decision, you can submit a formal appeal to the Illinois Workers’ Compensation Commission (IWCC). An arbitration hearing will then be held to resolve your case.

The arbitrator will analyze the evidence in your case and determine whether to reverse or uphold the insurer’s decision. If the arbitrator rules in favor of the insurer, you can still appeal that decision by submitting a Petition for Review to the IWCC within the required deadline.

Three IWCC commissioners will carefully examine your petition. They will then set a workers’ comp hearing date if they find any legal error that may have impacted your case outcome.

At the hearing, both sides will submit a written argument to the Commission and make oral arguments. The Commission will take the time to review the arguments and evidence presented by both sides and announce its decision within 60 days.

If the commission upholds the denial, your option for appealing that decision will be the state court system. This appeals process will start at the local circuit court, move to the appellate court, and end at the Illinois Supreme Court.

How a Workers’ Compensation Attorney Can Help

Appealing a denied workers’ comp claim can be stressful, confusing, and time-consuming. This process requires the involvement of someone who knows your state’s workers’ comp laws and has a proven record of successfully representing injured workers. So, hire a workers’ compensation attorney to streamline the appeals process and improve your chances of a positive outcome.

Review and Analyze the Denied Claim

A workers’ comp attorney will thoroughly evaluate the denied claim, examine the denial reasons provided in the denial letter, and find any possible weaknesses. The attorney will scrutinize medical documentation and investigate further to collect evidence.

Devise a Well-Thought-Out Legal Strategy

An effective legal strategy can help you stand a better chance at reversing a denied workers’ comp claim. Your attorney will consider the statutes and rules related to your case and all the compiled evidence to develop a legal strategy tailored to counter the denial reasons.

Your strategy may focus on legal mistakes in the denial decision or submitting new evidence to strengthen your case. It may also involve obtaining testimony from expert witnesses, such as medical practitioners, to develop a compelling case.

Negotiate and Settle the Case

Negotiating with the employer or the insurance company may generate a favorable outcome. Your attorney will present a persuasive argument during settlement negotiations and ensure any amount proposed by the insurance company is reasonable before advising you to consider accepting it.

Advocate for You During Hearings and Appellate Proceedings

Your workers’ comp attorney will defend your rights and argue your case before the arbitrator, Illinois Workers Compensation Commission, or administrative law judge (ALJ). The attorney will also help you appeal with higher courts and represent you during appellate proceedings.

At Martay Law Office, our attorneys have a success rate in workers’ comp cases. Contact us today to request a free consultation. 

David W. Martay David W. Martay
David W. Martay

David W. Martay, a partner at Martay Law Office in Chicago, IL, is a top-rated workers’ compensation lawyer who represents injured employees throughout the state. Known as a highly-skilled advocate for his clients, David has recovered millions for victims of workplace accidents.

Years of Experience: More than 25 years
Illinois Registration Status: Active

Bar Admissions: Illinois State Bar Association

David W. Martay David W. Martay
David W. Martay

David W. Martay, a partner at Martay Law Office in Chicago, IL, is a top-rated workers’ compensation lawyer who represents injured employees throughout the state. Known as a highly-skilled advocate for his clients, David has recovered millions for victims of workplace accidents.

Years of Experience: More than 25 years
Illinois Registration Status: Active

Bar Admissions: Illinois State Bar Association