By: Michael J. McConnell – workers’ compensation attorney in Ardsley, NY serving all of Westchester County and NYC, including Yonkers, White Plains, and the Bronx.
On top of the pain and uncertainty from a work-related accident, hearing that the insurance company denied your workers’ compensation claim can feel devastating.
After all, you thought that you did everything right: you reported your accident timely, you went to the doctor immediately, and you filed a workers’ compensation claim. You may have even spoken with your adjuster and answered all of their questions about the accident. They seemed so nice, helpful, and reassuring after that call. It seemed like your claim was going to be covered.
What happened? Why all of a sudden is the insurance company refusing to pay for your lost wages and medical treatment? Why are they saying your claim is denied?
These are all common questions that injured workers have after their claim is denied. In this article, I will discuss the following:
- Common reasons claims are denied.
- The basic process after a denial.
- Ways to fight back if your workers’ compensation claim is denied by the insurance company.
As always, this article is for general informational purposes and is not legal advice. If you are seeking legal advice, you should speak with a lawyer directly. Many workers’ compensation lawyers in New York, including the Law Office of Michael J. McConnell, offer free consultations.
1. Common reasons workers’ compensation claims get denied in New York.
In New York, work-related injuries are covered through workers’ compensation, which is basically a type of no-fault insurance that employers have for work accidents involving their employees.
In general, to get a work injury covered, these three things must be true:
- The injury occurred within the course and scope of the worker’s employment.
- The employer was notified of the accident timely. (Generally must be within 30 days of the accident.)
- A doctor credibly states in a medical report that the injury was caused by the work accident or employment duties.
- The claim was filed within the statute of limitations.
If those things are true, the claim should usually be compensable – meaning it is covered and eligible for benefits.
Additionally, there is a legal presumption in New York in favor of injured workers saying in essence that claims are presumed compensable unless the insurance carrier produces substantial evidence that the injury was not work-related. If they can’t meet that burden, then they really shouldn’t be denying the claim.
Here are some reasons why insurance companies can legally deny workers’ compensation claims in New York:
- Coming and going (e.g., accident during regular commute).
- Horseplay.
- Willful intention to injure oneself.
- Falls outside the worker’s compensation law’s definition of accident.
- Deviation from employment.
- Intoxication.
- Recreational or social activity.
- Presumption doesn’t apply.
- Stress not work-related.
- No medical evidence of injury.
- No injury per statutory definition.
- No employer-employee relationship.
- Independent contractor.
- Falls outside definition of employee under the WC law.
- Lack of jurisdiction.
- No coverage (insurance carrier doesn’t have policy for the employer covering the date of accident).
- Statute of limitations expired.
- Statute exempts claimant.
- Failure to report accident timely.
So to help illustrate some of these denial reasons, let me give a few examples of why an insurance adjuster might deny your claim.
- You got injured on your regular work commute to or from work and no exception to the “coming and going rule” applies.
- There is no medical report that says you were injured at work.
- The insurance company or your employer is saying you didn’t make a timely report of the accident.
- Your intoxication was the sole cause of your accident.
- The adjuster thinks your injury or condition is not work-related.
- The insurance company disputes whether your accident occurred as you said it did.
While the above situations (if true) can sometimes justify a denial, the truth is that insurance companies and employers often jump to conclusions way too quickly. They do so without diligently investigating the claim or carefully reviewing all of the facts.
Sometimes they have their mind made up the second they get the claim. Especially if they know it is going to be a costly one for them, they might look for any possible basis to deny it regardless of how weak their reasoning is.
For example, adjusters will make it seem like the “recorded statement” that they take from an injured worker after the accident is to help them get benefits. Yet the real reason for the recorded statement might be to pin down the injured worker on certain facts to bolster a denial of the claim.
If the investigation and recorded statement is not fair, impartial, and complete, there is a massive risk of an unjustified denial, which can have serious negative consequences for people hurt at work.
This is a huge reason why considering legal representation on a workers’ compensation case can be important. Workers might be experts in their particular job, but knowing how to deal with a savvy insurance company is quite understandably not something most people outside of the industry know how to do.
Among other things, an attorney from the beginning of the case (and even before the insurance company makes their compensability decision on whether to accept or deny the claim) can:
- Ensure that all of the necessary facts are put forth to substantiate the claim.
- Work with a doctor’s office to get medical documentation proving the injury was work related.
- Gather evidence supporting the accident and injury.
- Determine if there are witnesses who can help prove when, where, how, and/or why the accident happened.
As I will discuss further below, there are ways to challenge a denial, but if there is a chance to avoid one and have the case accepted from the start that is always best.
Litigating denials can take months to resolve, and during that time the injured worker will likely not be compensated or have treatment approved.
In cases where it is just a matter of getting the right facts in front of the insurance company, a workers’ compensation lawyer can prove helpful in avoiding a denial in the first place.
2. The Basic Process After a Denial in a New York Workers’ Compensation Case.
Once an insurance company denies the claim, they will issue a notice called a FROI-04. This notice will briefly list the reasons for the denial but will rarely go into much detail.
After the denial is filed, a pre-hearing conference will typically be scheduled with the New York State Workers’ Compensation Board (WCB).
Prior to that, however, the insurance carrier is required to file a form called the Pre-Hearing Conference Statement (PH-16.2) no later than 10 days before the pre-hearing conference. In the PH-16.2, there will be a few more details about the basis for the denial, including a list of evidence as well as any witnesses the carrier intends to call to support the denial.
If the insurance carrier fails to file the PH-16.2 timely and without good cause, they will be deemed to have waived certain defenses. A waiver of defenses is often fatal to a denial, so a late PH-16.2 can cause the denial to be reversed.
At the pre-hearing conference, both sides will generally appear virtually and the case will then be adjourned to a future date.
Prior to the next hearing, the judge might require either or both sides to produce certain evidence. For example, the judge might:
- order the insurance company to produce an Independent Medical Examination (IME) if they chose to do so;
- direct depositions of doctors;
- or require certain documents to be submitted.
At a subsequent hearing, there could also be testimony taken from any witnesses and/or the injured worker. Both sides will be allowed to make arguments before the judge, who will then issue a decision. Sometimes this entire process can take multiple hearings over the course of several months. Ultimately the judge will review all of the evidence and make a decision on whether the claim should be established or disallowed. If established, the injured worker will be eligible for benefits. If disallowed, the denial will stand. Either side can appeal the judge’s decision, and an appeal can take several months to be decided.
3. Common Ways to Fight Back Against a Denied Workers’ Compensation Claim in New York
As alluded to above, the insurance company doesn’t have the final say on a denial – the New York State Workers’ Compensation Board (WCB) does. So when a claim is denied, it can be critical to immediately begin fighting back.
The goal for an injured worker whose case is denied is to win before the WCB. Winning often requires a tremendous amount of diligence, a good legal strategy, and a relentless attack on the insurance company’s nonsensical arguments.
Here is a non-exhaustive list of things that can be done to fight back against a denial:
- Thoroughly explain to the insurance company that the denial is improper and that there will be serious negative consequences such as delayed medical treatment and compensation due to their error. If they don’t reverse course, then the issue will be aggressively litigated, which can be significant cost for them.
- Produce credible medical evidence showing the injury is work-related.
- Gather evidence, including photos, video, and any other relevant documentation.
- Find helpful witnesses and get them to testify on behalf of the injured worker at a hearing.
- Research the applicable legal issues and find the strongest arguments possible.
- Diligently prepare the injured worker for testimony.
- Identify any legal defects with the insurance company’s denial notice and PH-16.2.
- Conduct an aggressive cross examination of any witnesses testifying against the injured worker by – among other things – calling out any bias, lack of firsthand knowledge, and/or lack of credibility.
- Persuasively argue to the judge why the case should be established and why the insurance company’s arguments don’t make sense.
- File an appeal if the judge erroneously fails to establish the claim.
Every case is unique and depending on the particular facts of a given case there are countless other things can be done, but this list is intended to just give a basic idea of some common ways to attack a denial. As always, if you are facing a denial of your claim, you are encouraged to consult with an attorney.
Conclusion: Knowing your rights is critical as an injured worker in New York when faced with a denial.
Having a claim denied is a serious matter when you are out of work and in need of medical treatment. In New York, an insurance company’s denial of a workers’ compensation claim is not the end. There are ways to fight back, including litigating the case before the Workers’ Compensation Board. Having a sound strategy and knowing the right steps to take can make all the difference in winning your case. Injured workers have a right to an attorney and can consider legal representation, which can be especially important when a claim gets denied.
If you were injured at work in Yonkers, the Bronx, or the surrounding area, please contact the Law Office of Michael J. McConnell right now for your free consultation.
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Page Last Updated: 4/13/25.