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What you need to know about a workers’ comp claim denial

After suffering an injury on the job in New York, a worker may report the incident to the supervisor and seek medical attention assuming that the employer’s workers’ compensation insurance will cover the expenses and lost wages. While this may be true, there may be times when an injured employee’s claim is denied, even though he or she believes the eligibility requirements are met. Here are some reasons why, and what a worker can do about it.

The letter stating that the workers’ compensation claim was denied will include the reason for denial, Findlaw explains. Timeliness could be an issue, if the worker did not report the injury to the supervisor within the deadline, or if he or she missed the time limit for claim filing. Some injuries and illnesses are notoriously difficult to connect to a work-related incident, particularly those that develop over time, such as musculoskeletal disorders. The employer or the insurance company may dispute the eligibility of the claim for a number of other reasons, as well.

According to the New York State Workers’ Compensation Board, the injured worker can appeal the denial. The claims examiners for the Board will investigate the circumstances and may attempt to mediate a resolution between the parties. If this does not work, the authority to resolve the claim goes to a workers’ compensation law judge, who weighs the testimony of the insurance company and the worker, as well as evidence such as medical records.

The judge’s ruling to uphold the denial or set an award may not be final, as this decision may also be appealed. All of the members of the Board may be called upon to determine whether the judge’s decision should be upheld, but even after this, either party may take the case to the state’s appellate court system.

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Success Stories

  • A 43 year old ironworker who fell four stories and sustained injuries to his ankle while installing a staircase settled his claim for $1,500,000.00. The accident was due to the failure of the building owner and general contractor to provide a safe place to work.
  • A construction worker operating an asphalt roller settled his case for $525,000.00 when the edge of the roadway he was paving collapsed into a trench being dug by a subcontractor causing him to sustain injuries to his leg.
  • A 54 year old commuter settled his case against the NYCTA for $1,200,000.00. when he tripped and fell on a subway platform due to the pavement being in disrepair, causing him to fall forward and to strike his head on a train pulling into the station.
  • The estate of a 64 year old woman received a settlement of $425,000.00 after she was struck and killed by a speeding tractor trailer while crossing the street at the intersection of Richmond Terrace and Port Richmond Avenue.
  • A $1,200,000.00 settlement was reached on behalf of a 54 year old man from Staten Island, New York, who, while in the course of his employment as a bus driver, was rear-ended on the Garden State Parkway and caused to suffer injuries to his back and neck as well as a fractured rib and fractured pelvis.
  • A 47-year-old building superintendent who sustained injuries to his head and right side of his body due to a tripping hazard at his job site received a settlement of $300,000.00 from the electrical company performing work at the site.
  • A 43 year old construction worker was caused to sustain injuries to his back, shoulder and hand when the elevator he was riding malfunctioned and dropped 8 floors. He received $350,000.00 in the settlement of his claim against the building owner, maintenance company and elevator company.
  • The administrator of the estate of a 69 year old man who suffered stage four pressure sores while a patient at a Queens nursing home settled the case for $400,000.00 after the man died.
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