Private industry employers recorded 2.5 million nonfatal workplace injuries and illnesses in 2024, as reported by the Bureau of Labor Statistics. Workers’ compensation systems serving this many injured workers will necessarily deny some claims. But most denials are the start, rather than the end, of a claim. State programs allow for appeals.
The BLS report covering 2023 and 2024 states that the median case involving days away from work lasts 8 days. If a worker appeals and the process takes several weeks, the appeal time outlasts the absence from work. The programs differ in who hears the case, how much time the employee has to act, and how much paperwork is involved.
What a Denial Means
An insurance company or agency denying a claim is a decision that the worker can challenge. It means that there is a possibility that a claim doesn’t qualify for some benefits and has some issues that need to be resolved before benefits are granted.
A worker must understand why a claim was denied. The worker must then also determine the appropriate timing and procedure to file a request for review. A claim must be denied in writing, and once a worker receives the denial, the appeal time limit begins to run, particularly in Ohio.
An individual who assumes that a denial of their claim terminates their worker’s compensation appeal is likely to miss an important window. Knowing how to appeal a denied workers’ compensation claim is necessary for a worker. But keep in mind that it can differ greatly by state.
In Ohio, for instance, there are many elements to account for. These aspects include the steps to an appeal, what benefits are possible, techniques used by insurance companies to avoid payouts, and at what stage to employ the services of a lawyer.
Injuries That Draw Disputes
Overused body parts, such as back, shoulders, and knees, are prone to repetitive motion injuries over time, in comparison to other injuries that result from a sudden single event. Depending on where a worker resides, the locations of repetitive strain injury help are quite diverse. Carpal tunnel and tendonitis, along with other back and shoulder injuries from repetitive work, can be brought to a Los Angeles repetitive motion injury lawyer in cases of disputable claims.
Since claim procedures differ across jurisdictions, the sections below use two states as examples. Neither describes a national rule.
Ohio as One Example
According to the Ohio Bureau of Workers’ Compensation, claimants file their appeal with the Industrial Commission of Ohio, which resolves disputed claims. Appeals filed with the Bureau are forwarded to the Commission. The appeal must be submitted in writing, either using the Notice of Appeal form provided by the Commission or by filing a signed and dated document that contains the necessary details.
Appeals can be filed by mail, by fax, or in person at any local Bureau Customer Service Office or at any of the Commission’s offices. The deadline for submission is fourteen days following the worker’s receipt of the order, according to the Bureau. They outline the details of the deadline inside the order itself, making it necessary for the worker to understand this document first.
The appellant can have their case heard at the Industrial Commission office nearest their residence. Following the hearing, the parties will receive a written decision on the case by mail.
California as Another
The guide to the claims process issued by the Division of Workers’ Compensation for the state of California instructs workers to get in touch with an Information and Assistance officer should the insurance company decide to deny the claim.
The guide does not list a deadline for challenging a denial, but it does state that a claim is presumed accepted if the insurance company has not denied it within 90 days. The guide does have time frames that regulate some of the earlier steps in filing a claim. Employers must authorize medical care worth up to $10,000 within one day after the worker submits the claim form. Within 14 days, the insurance company must send one of three notices, which either accept the claim, put it on hold, or deny the claim altogether.
The examples above also illustrate the amount of dependency a worker’s situation has on their resident state. One state sets a 14-day written appeal deadline. Another directs denied workers to an assistance officer first. The Department of Labor (DOL) advises employees of state or local governments and private companies to contact their state workers’ compensation board. DOL’s own workers’ compensation programs, which replace income, pay for medical expenses, and provide vocational rehabilitation, cover federal workers and certain other groups.
For claimants that receive denials, there is typically a denial notice and guide. The guide covers most claims, but each state operates differently. One can check each state’s notice of denial to see how they handle denials, but the other requirements will be state-specific. Each state agency will likely have similar guides to outline these differences, even though different states handle each process and provide different rules.
