What To Do When Your Workers Comp Claim is Denied

If you’ve suffered a workplace injury, you may have expected workers’ compensation to cover your medical bills and lost wages.

But what happens if your claim is denied?

A denied workers’ comp claim can be frustrating and overwhelming, but it doesn’t mean you’re out of options. There are steps you can take to appeal the decision and fight for the benefits you deserve.

In this guide, we’ll walk you through everything you need to know about handling a workers’ comp claim denial, including why claims get denied, what your next steps should be, how to handle medical bills, and whether you can sue your employer for denying your claim.

Before we dive into the nitty gritty of a denied workers compensation plan, let’s first cover the basics.
Note: If you already know the basics about workers compensation and want to jump to the how-to information, click here.

What Is Workers’ Compensation?

Workers’ compensation (a.k.a. Workers comp) is a system designed to provide financial support to employees who suffer work-related injuries or illnesses. It is meant to cover:

• Medical expenses related to the injury.
• Lost wages while recovering and unable to work.
• Rehabilitation costs for physical therapy and recovery.
• Permanent disability benefits if the injury leads to long-term impairment.

Unlike personal injury claims, workers’ comp does not require employees to prove that their employer was negligent. As long as the injury happened while performing job-related duties, the worker should qualify for benefits—though, as we’ll discuss, claims are sometimes denied for reasons outside the employee’s control.

Let’s discuss why someone would make a claim, and then dive further into the approval and denial processes.

Why Would Someone Make a Workers’ Comp Claim?

An employee may file a workers’ comp claim for any injury or illness that occurs as a direct result of their job. Some common reasons for filing a workers’ compensation claim include:

• Slips, trips, and falls in the workplace.
• Repetitive motion injuries, such as carpal tunnel syndrome.
• Exposure to hazardous substances causing respiratory or skin conditions.
• Injuries from machinery or equipment accidents on the job.
• Work-related transportation accidents, such as truck or delivery driver crashes.

Workers’ comp exists to ensure that injured workers do not bear the financial burden of their injuries.

However, it’s important to note that just because you file a claim doesn’t mean it will automatically be approved.

What Do You Get With Workers Compensation?

When you’re injured on the job, workers’ compensation is designed to provide financial and medical support to help you recover. While the exact benefits vary by state, most workers’ comp programs offer the following:

1. Medical Coverage: Workers’ compensation pays for all reasonable and necessary medical expenses related to your workplace injury or illness. This can include:

• Doctor visits and hospital stays
• Surgery and medical procedures
• Prescription medications
• Physical therapy and rehabilitation
• Medical devices (e.g., crutches, braces, prosthetics)

However, in some states, you may be required to see a doctor approved by your employer’s insurance provider.

2. Wage Replacement Benefits: If your injury prevents you from working, workers’ compensation provides wage replacement, typically in the form of temporary disability benefits. These payments usually cover a percentage of your lost wages, often around two-thirds of your average weekly salary, up to a state-mandated cap.

Types of wage replacement benefits include:

• Temporary Total Disability (TTD): If you can’t work at all for a period of time.
• Wage Loss Compensation (WL): If you can work in a reduced capacity but earn less than before.
• Permanent Total Disability (PTD): If you can no longer work in any capacity due to your injury.

3. Permanent Disability Benefits: If your injury causes long-term or permanent impairment, you may qualify for permanent disability benefits. The amount depends on the severity of your injury and how it impacts your ability to work.

• Permanent Partial Disability (PPD): For injuries that limit, but do not completely prevent, your ability to work (e.g., loss of a limb or reduced mobility).
• Permanent Total Disability (PTD): For injuries that make it impossible to return to any type of work.

4. Vocational Rehabilitation: If you can’t return to your previous job due to your injury, workers’ comp may pay for:

• Job retraining programs
• Career counseling
• Tuition assistance for learning new skills
• Job placement services

This benefit helps injured workers transition into new roles or industries that accommodate their limitations.

5. Death Benefits or Compensation for Surviving Family Members: If a workplace accident results in a fatality, workers’ compensation provides benefits to the deceased worker’s dependents, which may include:

• Funeral and burial expenses
• Ongoing financial support for spouses and dependent children

These benefits help families recover financially after a tragic workplace accident.

How Do Workers’ Comp Claims Work?

Understanding the workers’ compensation process can help you navigate a claim denial more effectively. Here’s how the process typically works:

Step #1: Report the Injury

You must notify your employer about your injury as soon as possible and file the appropriate paperwork with the appropriate state agency to establish a claim. Each state has strict deadlines for reporting workplace injuries.

Step #2: Seek Medical Treatment

You should see an approved doctor to assess and document your injury. Medical records will play a crucial role in your claim.

Step #3: Claim is Filed

Your employer, health care provider or claimant submits the necessary paperwork to their workers’ compensation insurance provider.

Step #4: Insurer Reviews the Claim

The Ohio BWC or company assesses the claim, reviews medical records, and determines whether benefits will be paid.

Step #5: Approval or Denial

If approved, you receive benefits. If denied, you will receive a denial letter explaining why your claim was rejected.

If you’ve reached Step 5 and received a denial, it’s time to take action.

Understanding Why Your Workers’ Comp Claim Was Denied

If your workers’ comp claim was denied, the first step is to understand why. Some of the most common reasons for denial include:

Missed Deadlines

Each state has a strict time limit for reporting a workplace injury and filing a claim. If you don’t notify your employer or file your claim within this period, your case could be denied.

Insufficient Medical Evidence

Workers’ compensation claims rely heavily on medical documentation. If you don’t seek medical treatment immediately or your medical records don’t clearly link your injury to your job, your claim could be denied.

Employer Disputes the Injury

Your employer or their insurance company may dispute the claim, arguing that:

• The injury didn’t happen at work.
• The injury isn’t as severe as you claim.
• You were engaging in misconduct (e.g., intoxicated or violating workplace safety rules).

Pre-Existing Conditions

If the insurance company believes your injury was caused by a pre-existing condition rather than a work-related accident, they may deny the claim.

Paperwork Errors

Something as simple as missing documentation or errors on your claim form could lead to a denial.

Understanding What Happens to Medical Bills When Workers’ Comp Is Denied

If your claim is denied, you’re likely wondering who pays your medical bills. Here are your options:

• Use your health insurance: You may have to rely on your own insurance while appealing your workers’ comp claim.
• Negotiate a payment plan: Some medical providers allow payment plans while you pursue benefits.
• Seek reimbursement: If your appeal is successful, workers’ comp may reimburse you for out-of-pocket medical expenses.

An attorney can help you find ways to cover medical costs while your case is being reviewed.

What To Do After a Workers’ Comp Denial

If your workers’ comp claim is denied, don’t panic. You still have options.

A denial doesn’t mean your case is over. Follow these steps to fight for the benefits you deserve:

Step 1. Review the Denial Letter

Your denial letter should explain why your claim was rejected. Carefully review the reason given and determine what evidence or documentation might help you appeal the decision. It is important to note that there is a specific time period in which you can file an appeal to a BWC claim denial.

Step 2. Gather Additional Evidence

If medical evidence was lacking, work with your doctor to get more detailed records. You may also want to:

• Collect witness statements from coworkers.
• Request video footage if available.
• Keep a journal of your symptoms and treatments.

Step 3. File an Appeal

Each state has its own appeal process for denied claims. In Ohio, an employer’s decision to deny a claim or an appeal filed to a BWC decision will automatically get a claim set for a hearing before an Industrial Commission hearing officer.

Step 4. Get Legal Help

A workers’ compensation attorney can help you navigate the appeal process, present evidence effectively, and fight for the benefits you deserve.

Can You Sue Your Employer for Denying Workers’ Comp?

In most cases, you cannot sue your employer for denying workers’ comp.

Workers’ Compensation vs. Personal Injury Claims – What’s the Difference?

If your workers’ comp claim is denied, you might wonder if you should pursue a personal injury lawsuit instead.

Here’s how they compare:

Worker’s Compensation Lawsuit	Personal Injury Lawsuit
No need to prove fault	Must prove employer negligence
Covers medical bills and lost wages	Can include pain and suffering
Cannot sue employer	Can sue employer if they were negligent

An experienced attorney can help determine which legal path is best for your case.

If you’re on the fence about working with a lawyer on your workers compensation claim, consider this…

Why You Should Hire a Workers’ Compensation Attorney

An experienced attorney can protect your rights, handle the legal complexities, and fight to get you full compensation for your medical expenses, lost wages, and rehabilitation needs.

You should consider hiring a workers’ compensation lawyer if:

• Your claim has been denied: Employers and the Ohio BWC often reject claims due to lack of evidence, employer disputes, or paperwork errors. An attorney can appeal the decision and strengthen your case.
• Your employer is disputing your injury: If your employer or their insurer argues that your injury isn’t work-related, legal representation can help prove your case.
• You’re not receiving your benefits on time: Delayed payments for medical bills or wage replacement can cause serious financial strain. A lawyer ensures you get paid promptly.
• Your settlement offer is too low: Companies offer the lowest payout possible to save money. An attorney will negotiate for the full compensation you deserve.
• Your injury prevents you from returning to work: If your injury leads to a permanent disability, you need an attorney to secure long-term benefits, vocational retraining, or disability compensation.
• You’re being retaliated against: If your employer has fired, demoted, or otherwise retaliated against you for filing a claim, an attorney can protect your rights.

Fight for the Benefits You Deserve with Lee & Oehl

If your workers’ comp claim has been denied, don’t give up. You have the right to appeal, gather more evidence, and seek legal guidance to fight for your benefits.

At Lee & Oehl, we help injured workers overcome claim denials and get the compensation they deserve. We provide dedicated legal support to ensure injured workers get the compensation they deserve. We start with a free consultation – by gathering essential evidence, including medical records, accident reports, witness statements, and expert opinions, we build a strong case that supports your claim. Our team thoroughly investigates your workplace injury to strengthen your claim and fight for fair compensation, covering medical expenses, lost wages, disability benefits, and vocational rehabilitation.

If necessary, we represent you in hearings or court appeals to protect your rights. We also handle all paperwork and monitor payments to ensure you receive timely benefits.

Even after your claim is approved, we provide ongoing support, assisting with medical appointments, filing additional claims if your condition worsens, and addressing any disputes over benefit reductions.

Ready to let us fight for what’s right so you can focus on healing?

Schedule a FREE consultation today.