What Should I Do if My Workers’ Compensation Claim Is Denied?

January 27, 2025 @ 9:52 am

The guarantee behind workers’ compensation is that if you get injured at work, your employer is supposed to step up and pay for any medical attention you may need, cover lost wages on both a temporary and—if needed—permanent basis, help with vocational rehabilitation, and even reimburse you for mileage related to your injury’s treatment and rehab. If death results from a work-based injury, workers’ compensation is also supposed to provide death benefits for dependents. 

Yet, sometimes, these benefits are denied. If your workers’ compensation claim has been denied—or you worry that it’s about to happen to you—here’s what you need to know to move your case forward.

Who Pays for Workers’ Compensation Insurance?

Each state has its own laws governing workers’ compensation. In Louisiana, all employers must obtain and maintain a policy of workers’ compensation insurance for all of their employees. Employers pay monthly premiums for their workers’ compensation insurance policy, with premiums typically more costly for higher-risk jobs. What many of us don’t realize is that—like many other insurance products—workers’ compensation policies offer employers choices on how to cover their teams, known as Part A and Part B:

• Part A covers the mandatory coverage that Louisiana law requires for most employers—medical expenses, wage replacement, vocational rehabilitation and death benefits, for example.
• Part B provides employers’ liability insurance—coverage in case an employer faces a lawsuit due to a work-related injury or illness that falls outside the scope of traditional workers’ compensation benefits. Part B typically covers claims of employer negligence, third-party lawsuits and claims for injuries not covered by Part A.

While Part A coverage is required for most employers in Louisiana, Part B—while strongly recommended—is optional. So some cost-conscious employers may legally choose to carry only Part A as part of their basic workers’ compensation insurance policy.

Who Is Eligible for Workers’ Compensation?

Even if an employer has only one employee, that employer must purchase workers’ compensation insurance, and the provision includes not only full-time employees but also part-time and seasonal hires. However, some exceptions do exist.

Employers in Louisiana do not have to provide workers’ compensation coverage for certain workers under some specific circumstances. These are the exemptions:

• Certain employees of private residences. Domestic workers, casual laborers, family members and part-time workers employed for limited hours are all typically exempt. Some workers may opt for formal employment agreements to provide coverage or pursue legal compensation through an employer’s homeowners insurance or liability coverage or by filing a lawsuit.
• Certain employees of private unincorporated farms. Farm and agricultural workers are generally covered under mandatory workers’ compensation coverage, but workers on small farms with annual net earnings less than $1,000, for example, may not be covered.
• Certain musicians and performers. Independent contractors, temporary workers, small-scale productions and volunteers, for example, are not eligible. However, employees of larger productions, unionized performers and individuals who are actually classified as employees are eligible.
• Employees covered by certain federal laws. Most federal employees are covered under the Federal Employees’ Compensation Act—FECA. Federal employees may also be covered by specialized federal programs like the Longshore and Harbor Workers’ Compensation Act, the Federal Employers’ Liability Act, the Department of Defense, the Department of Veterans Affairs or the Defense Base Act.
• Employees of railroads or other vessels in interstate or foreign commerce. These individuals are covered under the Federal Employers’ Liability Act—FELA—due to the unique risks and conditions employees face.
• Crews of airplanes engaged in crop dusting or spraying operations. Aviation employers’ liability insurance, occupational accident insurance, or federal protections like the Jones Act or Federal Aviation Administration regulations may come into play, as well as private health and disability insurance.
• Most nonprofit volunteers. Nonprofits are often encouraged to carry volunteer accident insurance or general liability insurance to cover accidents involving volunteers.
• Landmen. A landman’s classification—independent contractor versus employee—affects coverage.
• Seamen. Certain maritime workers who qualify as seamen are covered under the Jones Act.

A significant determinant in establishing whether a person is covered under workers’ compensation is their classification as an actual employee versus an independent contractor.

• An employee is typically someone who works under the direct control or supervision of an employer and whose work is integral to business operations. Employees typically receive benefits like workers’ compensation, health insurance and retirement contributions.
• An independent contractor is a person or business hired to perform specific tasks, but they are not controlled or supervised by the employer in the same way employees are. Often, they are considered self-employed. They typically set their own schedule, use their own tools, for example, and have more autonomy over their work.

Key factors in determining the difference include the level of control an employer has over the work, the worker’s level of financial dependency for income, and the relationship between the worker and the employer.

The most important takeaway is that, in most situations, even if a worker is not eligible for workers’ compensation, they may be eligible to pursue compensation for their work-related injuries through another legal venue.

Reasons Why a Workers’ Compensation Claim May Get Denied

Filing a workers’ compensation claim is a formal process with firm rules and guidelines, so denials do occur. Often, delays and denials are related to improper procedures, eligibility requirements, or disputes about the injury or circumstances related to it. Unfortunately, claim denials are not uncommon, and navigating the reasons behind them can take some persistence.

• You failed to report the injury on time. In Louisiana, workers must report workplace injuries to their employer within 30 days of the incident. However, employers may be inclined to deny claims if the injury wasn’t reported immediately because delays in reporting can raise questions about whether the injury was later caused by something else. Reporting an injury promptly and ensuring you have witnesses can ensure that you have documented accounts of the incident.
• You failed to seek prompt medical treatment. Like delays in reporting an injury, delaying seeking medical attention can cast doubt on the severity or validity of an injury. In addition, workers must use an approved medical provider or risk having their claim denied.
• You were unable to link the injury exclusively to work-related activities. Injuries covered by workers’ compensation must be directly work-related. Injuries that occurred offsite, outside of work hours or outside the scope of employment do not qualify. Of note, Louisiana has a Coming and Going Rule. While travel to and from work is not normally considered part of employment, the state does recognize certain exceptions that merit workers’ compensation protections:
  
  • The injury occurred on the employer’s premises—the parking lot, for example.
  • The employee was on a work-assigned mission.
  • The employee was being paid travel expenses when the accident occurred.
  • The employee was doing work for the employer under implied consent.
  • The employee was injured while traveling between worksites.
  • The employee was injured in a hazardous area immediately adjacent to the place of employment.
  • Operating a vehicle is part of the employee’s job.
• You have a pre-existing condition. If an injury is related to a pre-existing medical condition rather than a new workplace injury, the claim may be denied. Workers’ compensation generally covers only the aggravation of pre-existing conditions if you can prove that the workplace worsened the condition.
• Your injury is not covered under workers’ compensation. For example, injuries resulting from intoxication or drug use are not covered, so an employer may require a post-accident drug screen. Failing to comply can result in a claim denial. Likewise, injuries that are self-inflicted, stem from intentional acts, are due to horseplay, occur during criminal activity or violate company policy are also ineligible.
• You missed the deadline for filing your claim. Workers must file their workers’ compensation claim with the employer’s insurance carrier within Louisiana’s statute of limitations—typically one year from the date of the injury.
• Your claim lacks the proper documentation. Claims are often denied because they lack essential evidence like medical records, witness statements and incident reports. Evidence of fraudulent or falsified claims can result in not only denial but also legal consequences.
• You failed to comply with the prescribed treatment plan. Benefits may be terminated or denied if you fail to follow the medical advice and treatment plan that the authorized healthcare provider prescribes. Missing medical appointments, refusing physical therapy or recommended procedures, not taking medications and engaging in restricted activities are all examples of noncompliance.

How to Appeal If a Workers’ Compensation Claim Is Denied

If your workers’ compensation claim is denied, that is not necessarily a final decision. A clear process is in place to allow you to dispute the denial and seek the benefits you are entitled to.

• Identify the reason for denial. The denial letter from the insurance company should explain the specific reasons for the rejection and note any concerns about your claim. Those points highlight what your appeal needs to focus on.
• File Form 1008. File a Disputed Claim for Compensation, Form 1008, with your local Office of Workers’ Compensation Administration—OWCA—district office. Louisiana has multiple district offices based on geographic regions. You typically have one year from the date of the injury to file this form. If your benefits were initially approved but later denied, you have one year from the last payment date to file your disputed claim.
• Collect all supporting evidence. To address the concern for denial, you most likely will need to strengthen your case. This often means gathering and organizing additional documentation like complete medical records, incident reports, and proof of compliance showing that you followed prescribed treatments or reported the injury promptly, as well as providing employment records, for example, proving that you were working when the injury occurred.
• Prepare for mediation. After receiving your Form 1008, the OWCA district office will schedule a mediation session between you and the employer’s insurer to resolve the dispute without a formal hearing. The mediator is a neutral third party but cannot make binding decisions. If both parties reach agreement, the mediator will draft a settlement. If not, the case proceeds to a hearing.
• Attend your workers’ compensation hearing. If mediation fails, your case will go before a workers’ compensation judge. Both sides will present evidence and arguments. Witnesses are typically called to testify and often include medical experts. Ultimately, the judge reviews all evidence and makes a decision.
• Appeal the judge’s decision. If you disagree with the judge’s ruling, you can appeal the decision to the Louisiana Court of Appeal within 30 days of the judge’s ruling.

Keep in mind that throughout all of this process, the insurer who already denied the claim or terminated benefits will most likely be working to keep that denial in force.

When to Seek Legal Support for a Workers’ Compensation Claim

Deciding when to involve a workers’ compensation attorney can be crucial in ensuring that you get all of the benefits you are entitled to. While not every claim requires legal representation, certain situations make hiring a lawyer essential—especially if your claim is already facing denial.

• If your claim is denied. If the insurer denies your claim, you will need legal expertise to file a Disputed Claim for Compensation and challenge the denial with appropriate evidence.
• If your benefits are delayed or stopped. Insurers sometimes delay or cut off benefits without explanation. A lawyer can push for timely payments, accountability and penalties for unjust delays.
• If your employer disputes the claim. Your employer may attempt to claim that the injury did not happen at work or dispute your version of events. A lawyer can investigate and present appropriate evidence to prove otherwise.
• If the settlement offer is inadequate. Insurers often offer low settlements to save money. An attorney can assess your claim’s true value and negotiate for a fair amount of compensation—including future medical care or disability benefits.
• If your injury is serious or permanent. Cases involving permanent disability, long-term treatment and care, or significant wage loss are more complex. Legal representation ensures that you are properly compensated for the long-term impact on your life and career.
• If your employer retaliates against you. If your employer fires, demotes or retaliates against you in any way for filing a claim, you will need an attorney to protect your rights and pursue damages.
• If pre-existing conditions are blamed. Insurers may argue that your injury is due to a pre-existing condition rather than a workplace incident. A lawyer can help prove the connection between the injury and your job.
• If you are asked to attend an independent medical exam. Insurers may request an IME to evaluate your injury. An attorney can prepare you for the exam and challenge any biased findings.
• If you are unsure of any part of the claim process. Workers’ compensation claims involve tight deadlines, complex paperwork and detailed medical evidence. If you are unsure about your rights or how to proceed, consulting an attorney early can prevent costly mistakes.

Pursue Your Claim with MMRBH

If you’re struggling with a workplace injury or the complexities of filing a workers’ compensation claim, it’s time to reach out to the experienced workers’ compensation lawyers at Morrow, Morrow, Ryan, Bassett and Haik. We know how to navigate complicated situations, build a strong case, negotiate with insurers, represent you through appeals and, most importantly—hold insurers accountable. e consultation with Morrow, Morrow, Ryan, Bassett and Haik, and let us fight for the best possible outcome right now.

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