Denial of a disability claim or workers’ compensation claim is frustrating, and it usually comes after weeks or months of paperwork and doctor visits. The denials are prevalent but can often be reversed by providing new or additional evidence about yourself, your medical history, physical limitations, or other missing information.
The positive news is that there is almost always an organized appeal procedure to reconsider denial. You just need to move fast, know why the claim was rejected and provide specific evidence that will resolve the specific problem. Don’t hesitate to seek the advice of an experienced disability or workers’ compensation attorney before filing your claim. Most lawyers here offer free consultations, and InPerSuit makes it easy to connect with them.
Denial of disability claims
- Insufficient medical proof. Decision makers require objective data demonstrating a diagnosed condition and the functional limits that are ensuing. Denial is usually caused by records showing only symptoms or prescriptions, but no test results or opinion on work limits by a doctor.
- Work and earnings conflicts. In the case of Social Security disability, high regular earnings beyond the limit of the program can indicate that you are doing a great job. In the case of private short-term or long-term disability coverage, the part-time earnings or consulting earnings may lead to offsets or exclusions when not reported appropriately.
- Poor records or omission of treatment. Lapses in care, failure to attend follow-up appointments, or notes reflecting disparate accounts of an injury etiology can undermine credibility. Timelines are used by decision makers.
- Waiting period and policy exclusions. Most private policies do not cover everything, only provide benefits in mental health claims, or demand that you meet a waiting period before benefits are paid. Any claims submitted prior to the elimination or beyond the notice deadlines are usually rejected.
- Inability to achieve the program definition. Some programs demand that you are unable to do any work in the national economy, not just what you used to do. The claim can be dismissed in case the file does not cover transferable skill or the practical effect of pain, fatigue or cognitive constraints.
Reasons behind the denial of workers compensation claims
- Late reporting. In most states, you are obliged to inform your employer immediately. Even a few days’ wait will cause insurers to doubt the work relatedness of the injury.
- Disputes about causation. The insurer may decline a claim should it feel that the injury was caused by a non-work-related activity, a pre-existing condition, or an event that occurred on a weekend. Concrete incidents reports, witness accounts, and medical notes that could identify the injury as a result of a particular work task are essential.
- Findings of independent medical examinations. The doctor of an insurer may determine that the injury is work-related, temporary, or minor. The opinion of the treating doctor is not always the deciding opinion unless it is a detailed opinion.
- Light duty or return to work. A claim can be damaged by refusal to take a suitable light duty job, or to work beyond medical limitations. Written limitations by your physician can be useful to avoid misunderstanding.
- Monitoring and surveillance. Out of context photos or short videos may be taken. Even the normal things can be modeled as evidence that you are not hurt.
What to do to contest a disability rejection
- The first thing to do is to read the denial letter. Note the deadlines. The decisions taken by the social security disability program typically allow a limited period of time to seek a reconsideration and a hearing before an administrative law judge, where necessary.
- The next is critical. Consult an experienced disability lawyer. Failing to follow reconsideration or appeal procedures can result in your claim being permanently closed. It’s equally important to present specific supporting evidence at this stage. Disability claims are often decided on factual details, which are best developed by an experienced advocate.
- Request your treating physician to write a narrative report detailing your diagnosis, objective findings, treatment side effects and how these restrict work activities such as lifting, standing, concentration, attendance and pace. The symptoms can be translated into work-related limits using Functional Capacity Evaluations and standardized questionnaires.
- Describe work experience and transferable skills. A vocational statement may demonstrate that your education, experience, and age do not permit a realistic transition to other occupations. When your condition varies, record off-task time and when you need unscheduled breaks in a symptom diary and third-party statements.
- Submit all evidence in writing. Add new records, test reports, drug regimens, treatment notes, and a brief cover letter that relates each exhibit to the cause of refusal. Keep copies of all that you send.
What to do if your workers’ compensation claim is denied
- Consult a workers’ compensation lawyer. If you filed your workers’ compensation claim with your employer or a third-party administrator, now is the time to speak with an experienced work comp attorney – especially if you haven’t already.
Ideally, it’s best to consult a lawyer before filing your claim. But even at this stage, an attorney can help you understand why your claim was denied and guide you through the appeals process. Most work comp lawyers on InPerSuit offer free consultations, making it easier to take this important step without added cost. - File a formal lawsuit or appeal on time. If your workers’ compensation claim is denied, you still have options—but you must act quickly. Depending on your state, you will have to request a hearing, initiate a lawsuit, or file a formal appeal. Each state has its own procedures and strict deadlines, so make sure you understand what applies in your jurisdiction. You’ll typically need to include the denial letter and any required forms to your state’s workers’ compensation agency. Missing a deadline or submitting incomplete paperwork can result in the permanent denial of your claim.
- Address medical causation proactively. Request that your treating physician discuss the issue of causation in simple terms, such as that the work incident was a major cause of the injury. When the insurer requests an independent medical exam, it’s best to counter with a point-by-point refutation of your doctor and any other specialist who is examining you.
- Collect non-medical proof. OSHA logs, photos of the worksite, job descriptions, time sheets and statements by supervisors or coworkers can prove that the injury occurred at work and that you complied with reporting requirements. In case you have been offered light duty, you can collect the written offer and restrictions by your doctor to demonstrate whether this assignment was appropriate or not.
- Prepare your case. Most states require a settlement conference or mediation before the final hearing. If your case doesn’t settle, your credibility will play a major role in the outcome. Be honest, provide clear and consistent testimony, and focus on how your injuries affect your ability to perform the job. A skilled workers’ compensation lawyer can help you prepare, strengthen your case, and maximize your potential award.
Effective actions that make any appeal stronger
- Meet every deadline. Make notes on your calendar and submit through a trackable means.
- Keep treatment consistent. Keep all appointments and adhere to given care unless a physician tells otherwise.
- Communicate accurately. Describing the accident or condition in all forms and visits Use the same description.
- Limit social media. Even innocent posts can be misunderstood.
- Organize your information and evidence. Store a folder of denial letters, forms, medical records, test results and wage information.
- Hire the right lawyer. A skilled workers’ compensation lawyer does far more than fill out forms. They serve as your advocate through a complex and often adversarial process. They’ll gather medical records, coordinate expert opinions, challenge insurer-appointed doctors when necessary, and present a compelling case on your behalf at hearings or mediation. When searching for a lawyer, InPerSuit makes the process easier by helping you compare, evaluate and connect with qualified lawyers confidently.
Final note
If your workers’ compensation or disability claim has been denied, time is critical. Consulting with an experienced attorney early can make all the difference in securing the benefits you deserve. InPerSuit’s skilled legal professionals are ready to connect you with vetted lawyers in your area who offer free consultations for workers’compensation and disability claims.