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Workers’ compensation claim requirements and dealing with denials

On Behalf of | Jan 10, 2023 | Workers' Compensation

Most employers carry workers’ compensation insurance, and it covers employees that receive injuries while on the job. Benefits often include wage replacement, medical care and disability compensation.

An injured worker must file a claim to receive these benefits, and there are certain requirements for doing so. Denials are not uncommon, and following the requirements helps with approval and when fighting a claim dispute.

Requirements for filing a claim

According to the New Jersey Department of Labor and Workforce Development, one of the requirements, when there is an injury, is to inform the employer soon after the accident. It does not have to be a written notice, but doing so may help a claimant’s case in the event of a denial.

After receiving the report, the employer must inform the insurance company about it, and they will evaluate the claim. There is also a deadline for the filing of the claim. The company will then issue an approval or denial of the claim.

Reasons for a denial

FindLaw discusses that not meeting reporting and filing deadlines are common reasons for denials. However, there are additional ones:

  • There is insufficient evidence the injury occurred at work
  • The injury occurred due to horseplay, self-infliction or substance use
  • The worker did not receive medical care, or he or she did not use the provider named by the insurance carrier or employer

How to appeal a claim denial

If the insurance company denies the claim, or the employer disputes the claim, the injured worker must file an appeal within a stated time frame. The employee appears in front of a judge and states his or her case. This is the time the worker should present all relevant evidence, such as witness testimonies and medical documents.