What Should I Do When My Claim is Denied?

The first thing to do is to immediately seek legal advice.   You should speak to an attorney or the Information and Assistance Officer at your local Workers’ Compensation Appeals Board right away. There are strict deadlines as to when you need to object and file documents.

After you have made such arrangements, you should do as follows: read your denial letter carefully.   The denial letter will tell you important information as to why the claim was rejected.   The following are reasons for which your claim was denied:

Coverage: the insurance company for which the claim was provided to is not the one who insured the Employer

Coverage: the insurance company for which the claim was provided did not insure the Employer on the date of injury

Lack of Information:  the insurance company does not have medical reporting from a doctor indicating that a work injury occurred.

Lack of Information: the insurance company has not received information  from the employer indicating that you were injured at work

Lack of AOE/COE:  (Arising out of and in the course and scope of employment), the insurance company received a medical report indicating that the injury was not work related.

Lack of AOE/COE:  (Arising out of and in the course and scope of employment), the insurance company received an investigation from the employer that they have information that the accident did not happen at work.)

Lack of AOE/COE:  the insurance company denies that what the injured worker did to get hurt arose out of and was in the course and scope of employment.

In these matters, it is important to obtain medical evidence and documentation to support your claim of injury. This would include obtaining medical records and/or obtaining a Qualified Medical Evaluation or an Agreed Medical Evaluation. This could also include obtaining personnel or payroll records.  Also, if there was an accident report, that would assist.

Again, it is very important to obtain legal counsel or legal advice to object to the denial and obtain evidence to support your claim.  Also, filing an Application at the Workers’ Compensation Appeals Board is also required within a specific time period.