If you’ve had an on-the-job injury or developed a chronic condition because of your work, you’re probably hoping to collect workers’ comp benefits. But employers’ insurance companies often deny claims by injured workers—sometimes even when the claims are legitimate. What can you do when that happens to you? The answer may hinge on why your claim was denied. Read on for details.

Basic Eligibility for Workers’ Comp: Employment and Insurance

Aside from the details of your injury and claim, you must meet the first two eligibility requirements for workers’ comp coverage:

• You were an employee when you were hurt. Workers’ comp doesn’t cover independent contractors (like freelancers and other “gig” economy workers). But some employers classify workers as independent contractors when they’re really employees. If that’s the reason your claim was denied, you may be able to fight it on appeal (more on that below).
• Your employer has workers’ comp insurance. Nearly all states require most employers to carry insurance policies or insure themselves to cover workers’ compensation. Learn what you can do if your employer doesn’t have workers’ comp insurance.

When Injuries Aren’t Work Related

Your claim will probably be denied if your employer or the insurance company doesn’t believe your injury or illness was actually work related. As a general rule, you’ll only be covered under workers’ comp if:

• you were hurt or got sick while you were doing something for your employer’s benefit, and
• your work was the cause of your injury or illness.

So you could be covered if you were hurt on a business trip or while you were doing other work away from the office or job site. However, injuries that happen during your normal commute to and from work are generally not covered under workers’ comp.

Even if you were hurt at the workplace, the insurance company may argue that your job wasn’t the cause of the injury. Although workers’ comp is generally a no-fault system, most states rule out coverage for injuries resulting from certain kinds of misconduct, like alcohol or drug use, horseplay (unless the employer knew about and tolerated the behavior), or hurting yourself on purpose.

The Impact of Preexisting Conditions on Workers’ Comp Claims

As a rule, workers’ compensation doesn’t automatically rule out coverage just because you had a previous medical condition or injury to the same part of your body that was affected by the most recent work injury. For instance, say you had a back condition from an old car accident and then you hurt your back again while lifting heavy boxes at work.

Generally, you should still be eligible for benefits if the recent injury aggravated the preexisting condition. However, the insurance company may deny your claim or try to minimize your benefits by insisting that the preexisting condition is largely responsible for your need for medical care or permanent disability benefits. When that happens, you may face an independent medical exam and other proceedings to resolve the medical dispute.

Minor Injuries

The insurance company will probably deny your workers’ comp claim if your injury wasn’t serious enough to require medical treatment or time off from work. The best way to combat this type of denial is to get treatment for your injury as soon as it happens and tell the doctor that it happened at work. If you try to tough it out and work through the pain, you could have a hard time convincing the insurer that you were hurt as badly as you claim.

Missed Workers’ Comp Deadlines

In order to be eligible for workers’ comp benefits, you must meet your state’s deadline for reporting the injury to your employer. Typically, you should give this notice within about 30 days, but the deadline may be a short as a few days. Whatever the deadline in your state, it’s best to report the injury as soon as possible. If you wait, the insurance company is more likely to be suspicious of your claim.

In many states, you’ll also have to file an official claim with your state’s workers’ comp agency within a time limit. But even when you miss the deadline, you might qualify for one of the limited exceptions.

What to Do About a Denied Claim

If your claim was denied but you continue to believe it was legitimate, you may appeal the decision. (Learn how other injured employees fared after their workers’ comp claims were denied.)

States have different time limits and procedures for appealing workers’ comp denials. The appeals process can be complicated, requiring additional paperwork, evidence gathering, and presenting your case at settlement negotiations or hearings. If you’re considering an appeal, a good workers’ comp attorney can help you through the process. (See our survey results on how much workers' comp lawyers cost.)