Appealing a Denied Workers’ Comp Claim in NYC

Our workers’ compensation attorneys can guide you through the process

Applying for workers’ compensation benefits in New York City can be a complex and daunting process. You’re supposed to get workers’ comp if you are hurt on the job, but it’s not always that simple in practice. Sometimes, claims are denied entirely, or insurance companies deny medical treatment or dispute the extent of an injured worker’s disability.

Many seriously injured employees and their families feel helpless when claims are denied. But they have options. Pasternack Tilker Ziegler Walsh Stanton & Romano LLP is a New York City workers’ compensation law firm with more than 90 years of experience fighting for workers’ rights. Our workers’ compensation lawyers have a deep understanding of what to do when claims are denied. Here’s what workers need to know.

Understanding New York workers’ compensation

Workers’ compensation is no-fault insurance that employers are required to purchase. It provides financial benefits for workplace injuries or illnesses. Benefits are typically available to all employees regardless of residency, citizenship or immigration status, hours worked per week, or hiring date. New York workers’ comp covers medical expenses, partial replacement of lost income, and additional benefits for certain permanent injuries.

When NY workers’ compensation claims are denied, the injured or ill employee will be informed. Typically, the reasons for the denial are explained in the Notice of Controversy, which the worker may receive. Commonly cited reasons for denial include:

• Inaccurate information, missed deadlines, and other clerical or administrative application process errors.
• The injury was not work-related.
• Disputes over the cause, extent, and medical treatment of injuries.
• Preexisting conditions.
• Failure to seek medical attention.
• Disputes about the length of recovery and ability to return to work.
• The injury was intentional or occurred in a fight that the worker started.

A workers’ compensation insurance company may deny the entire claim, for instance because they believe the injury was not work-related. Or they may dispute whether a particular medical treatment is “reasonable and necessary,” or argue that the injured worker is able to return to work.

If a claim is disputed or denied, a hearing will be held before an administrative law judge (ALJ) to resolve the dispute. There are multiple steps in this process, including a pre-hearing conference and a formal hearing. If the injured worker disagrees with the ALJ’s decision, they have the right to appeal.

Levels of workers’ compensation appeals in New York

In New York, the workers’ comp appeal process involves multiple levels:

1. Review by the Workers’ Compensation Board

Application for Board Review (Form RB-89) seeks a review of the ALJ decision. This form must be filed within 30 days of the date of the ALJ’s ruling. A panel consisting of three members of the Workers’ Compensation Board will review the decision and decide whether to affirm it, modify it, or rescind it. The three-member panel may also send the claim back to the judge for additional consideration. This decision is known as the Board Panel Decision.

Either party can request a Full Board Review of the panel’s decision. If the three-member panel was not unanimous, then the full Board must review the decision if requested. If the three-member panel was unanimous, then the full Board has discretion whether to review the Board Panel Decision or let it stand.

2. Appeal to State Courts

The decision of the Workers’ Compensation Board can be appealed to the Appellate Division, Third Department, Supreme Court of the State of New York. This appeal must be filed within 30 days of the Board’s decision. The Appellate Division appeal will be reviewed by a panel consisting of five judges.

A Notice of Appeal to the Appellate Division must be filed within 30 days of the Board decision. The appeal itself follows a timetable set by the court’s rules, which includes several intermediate deadlines that can vary depending on the circumstances. The Appellate Division has the authority to affirm, reverse, or modify the Board’s decision.

The Appellate Division’s decision can itself be appealed to the New York Court of Appeals, which is the highest court in the State of New York. Again, this appeal must be filed within 30 days of the lower court’s decision. The Court of Appeals normally only considers cases that involve an unusual question of workers’ compensation law.

Get help with denied workers’ compensation claims in New York

While every injured worker has the right to appeal, navigating the appeals process on your own is an uphill battle. There are strict deadlines and exacting legal standards that must be met in order to successfully appeal a denied claim. The workers’ comp insurance companies deal with this process every day, and they have experienced lawyers defending their interests. You need to level the playing field with experience and resources on your side.

When you’re facing a work-related injury or illness, the last thing you need is to handle a complex legal process on your own. For over 90 years, the New York workers’ compensation lawyers at Pasternack Tilker Ziegler Walsh Stanton & Romano LLP have been helping injured workers navigate the system and get the benefits they deserve.

If you were injured on the job and are facing a denied or disputed claim, contact us for a free case consultation. You have rights under New York law. We will fight for you every step of the way.

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