What To Do If Your Workers’ Compensation Claim Is Denied

An experienced attorney can guide you through the process

When workers are hurt in a workplace accident, their lives can be impacted in many ways. They need medical treatment and may be unable to work. This can lead to financial stress, and many workers may wonder how they are going to get by.

New Jersey’s workers’ compensation system is designed to help these workers. If you suffer a workplace injury, you should be eligible to receive workers’ compensation benefits. These benefits cover the cost of reasonable and necessary medical treatment for your injuries, and also provide partial lost wages if you can’t return to work.

If you were injured, workers’ compensation benefits can help you and your family get through a difficult time. But in far too many cases, claims are denied and workers are left wondering what to do.

Why are workers’ compensation claims denied in New Jersey?

There is a wide range of reasons that insurance companies and employers may give. For example:

There was a delay in seeking medical treatment. Insurance companies and employers may question your injury if you did not seek immediate medical treatment. But a worker may have experienced delayed symptoms or faced an obstacle that prevented them from seeking treatment sooner.
Deadlines were not met. Workers are required to report a workplace injury to an employer promptly in order to preserve their right to benefits. And a claim for benefits must be filed within two years of the date of the injury.
The worker was an independent contractor rather than an employee. Workers’ compensation protects employees, not contractors. There may be a dispute regarding how the worker should be classified for workers’ compensation purposes.
There was a pre-existing condition. This may be interpreted by the insurance company as evidence that an injury was not work-related – even though it clearly was.
The injury occurred away from the workplace or outside usual working hours. However, that alone does not mean the injury was not work-related. A worker may have been sent to another location or asked to work different hours.
The injury is not eligible because of the worker’s actions. Any injury that is found to be caused by willful misconduct or horseplay, self-inflicted harm, alcohol or drug use, or failure to follow procedures may result in a denial of benefits.

In addition, even if the claim is not denied entirely, the insurance company may dispute portions of the claim. For example, the insurance company may argue that a particular medication or medical procedure is not “reasonable and necessary” treatment for the work injury. They may also dispute the extent of a disability or the amount of the worker’s average weekly wage.

What can you do if your workers’ compensation claim is denied or disputed?

That’s not the end of your claim. You have different options for appealing the decision to the Division of Workers’ Compensation.

Informal hearings

One option is to try to resolve the dispute through a discussion with the insurance company in the presence of a judge. (In cases involving injuries to the fingers or toes, these hearings are required.) The process begins by filing an “Application for Informal Hearing.” A hearing is then scheduled, usually within weeks.

Before the hearing, both sides submit accident reports, medical records, and other documentation to the judge for review. During the hearing, the judge may ask you questions about your claim. You may also be asked about your injuries and the medical treatment you are getting. Other questions may be about how injuries have affected your daily living and ability to work.

The judge can make a recommendation for resolving the dispute and settling the claim. If both parties agree, a binding agreement will be signed. But either side can choose to reject the recommendation. Another informal hearing may be scheduled, or you may choose to move forward in the appeals process.

Formal hearings

If a resolution can’t be reached during an informal hearing, the next step is a formal hearing, which is similar to a trial. The process begins by filing a formal Claim Petition. A hearing is scheduled before a judge, usually within six months.

There are 15 workers’ compensation courts that serve different parts of the state. These are located in:

Atlantic City (serving Cape May and Atlantic Counties)
Bridgeton (serving Cumberland and Salem Counties)
Camden (serving Camden and Gloucester Counties)
Freehold (serving Monmouth County)
Hackensack (serving Bergen County)
Jersey City (serving Hudson County)
Lebanon (serving Somerset, Hunterdon and the southern half of Warren County)
Arlington (serving Sussex, Morris and the northern half of Warren County)
Mount Holly (serving Burlington County)
Newark (serving Essex county)/
New Brunswick (serving Middlesex and eastern Somerset County)
Paterson (serving Passaic County)
Plainfield (serving Union County)
Toms River (serving Ocean County)
Trenton (serving Mercer County)

A worker – usually through an attorney – can file a Motion for Medical and Temporary Benefits. If granted, this allows the workers to receive benefits before a final decision is reached.

Both sides prepare for trial. At the same time, they may continue negotiations to try to resolve the dispute. If they are able to reach an agreement, the trial will no longer be necessary. But if they can’t, the process will continue.

As in any other trial, each side will be given a chance to present their case. Each side can give an opening statement. Evidence will be presented and witnesses will be called. Your lawyer may want you to take the stand to discuss your injury and how it has impacted your life. Your doctor may be called to testify about your injury and the medical treatment that is required. Other witnesses may include co-workers.

After both sides have presented their case, they can give a closing statement. Once the hearing has concluded, lawyers have the opportunity to file post-trial briefs, and the other side given an opportunity to respond.

Within 30 days of the last day of the hearing or the date of the filing of briefs, the judge will reach a decision on your claim. Both sides will be sent written notification of the decision, which is binding.

Appeals court

If you do not agree with the judge’s ruling, you can appeal to the state courts of New Jersey in the Appellate Division of the Superior Court. Each side will have another opportunity to present their case. If needed, it may be possible to appeal the ruling all the way to the New Jersey Supreme Court.

An experienced New Jersey workers’ compensation lawyer can help.

While there is no requirement for you to get an attorney to handle your claim, it is in your best interests to have legal representation. An experienced lawyer will understand why claims are denied, and can build a strong case for benefits to move your claim forward.

Shebell & Shebell, LLC has been fighting for the injured in New Jersey since our firm’s founding in 1927. Our workers’ compensation attorneys understand what workers and their families are going through after a workplace injury. That’s why we’re dedicated to helping them get the results they need.

If you were hurt in a workplace accident, learn more about how we can help. Contact us to schedule a free consultation.

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