The official-looking envelope contains a single, stark word: DENIED. The entire system feels like it has turned against you at that moment. The pain from your work injury is real, your inability to earn a paycheck is real, yet a claims adjuster has dismissed it all with the stroke of a pen.
This is not the end of the road. It is the beginning of a formal legal process. When you get this notice, knowing what should I do if my workers comp claim is denied involves taking immediate and specific legal steps.
The attorneys at Rosenthal, Levy, Simon, & Sosa manage this appeals process, working to challenge the insurer's decision and pursue the benefits the law provides for injured workers.
Key takeaways pertaining to denied workers’ comp claims
- A denial of your workers' compensation claim is not the final decision. You have the right to appeal this decision through a formal legal process.
- The first and most important step after a denial is to file a Petition for Benefits with the Florida Division of Workers' Compensation.
- Strict deadlines apply. You must file this petition within the legal time limit, known as the statute of limitations, or you will lose your right to pursue the claim.
- The reason the insurance company gave for the denial is the key to your appeal. Your attorney will build a case with evidence designed to directly counter that specific reason.
- The appeals process involves evidence gathering, depositions, and a mandatory mediation conference designed to resolve the dispute without a trial.
Common Reasons for Workers' Comp Claim Denials
The denial notice you receive from the insurance company must state the specific reason for their decision. This reason is not just a formality; it is the entire basis of their argument and the exact point your legal team will work to disprove.
The injury was not reported promptly
Florida law requires you to report a workplace injury to your employer within 30 days. If you waited longer than that, the insurer will use it to deny the claim, arguing the delay makes the injury's origin questionable.
The injury did not occur in the course and scope of employment
The insurance company may argue that you were not "on the clock" or performing a work-related duty when the injury happened. This is common in cases involving breaks, travel, or injuries that happen on company property but outside of direct work tasks.
The condition was pre-existing
This is one of the most frequent reasons for denial. The insurer will claim that your injury is not the result of a new work accident but is instead a flare-up of a previous injury or a degenerative condition you already had.
Discrepancies in your account
The insurance company will look for any inconsistencies between your initial report of the injury, your statements to doctors, and other evidence. They will use any perceived contradiction as a reason to question your credibility and deny the claim.
Your First Legal Step: The Petition for Benefits
Once your claim is denied, you cannot simply call the adjuster and ask them to reconsider. You must initiate a formal legal process. In Florida, this is done by filing a Petition for Benefits (PFB).
The PFB is a legal document that is filed with the Florida Division of Workers' Compensation. This petition formally disputes the insurance company's denial and asks a Judge of Compensation Claims to intervene. It outlines the details of your injury, the benefits that were denied, and why you believe you are entitled to them.
The strict deadline to file
Filing the Petition for Benefits is subject to a strict deadline known as the statute of limitations. Generally, you must file the PFB within two years of the date of your injury or within one year of the last payment of compensation or provision of medical care.
Missing this deadline will permanently bar you from pursuing your claim. An attorney ensures this critical deadline is met.
The Discovery Process: Building the Case for Your Appeal
After the PFB is filed, your case enters a phase called "discovery." This is a formal, court-supervised process where your attorney gathers all the evidence needed to prove your case and counter the insurer's reasons for denial.
During discovery, your legal team works to build a comprehensive file. This process is designed to uncover all the facts and create a complete picture for the judge. Here are the key components of the discovery process:
- Requesting all medical records: Your attorney will obtain a complete set of your medical records, including those from before the accident, to establish the nature and extent of your work injury.
- Taking depositions: A deposition is sworn testimony taken outside of court. Your lawyer will question witnesses, your employer, and the insurance company's doctors under oath to get their official statements on the record.
- Obtaining expert opinions: In many cases, it is necessary to get an opinion from an independent medical expert who can provide an unbiased assessment of your condition and its cause.
- Gathering other evidence: This can include security footage of the accident, witness statements, employee handbooks, and maintenance logs, depending on the specifics of your case.
This evidence is meticulously compiled to create a strong argument that directly addresses the insurance company's reason for the denial. This thorough preparation is essential for success at the next stage.
Mediation: The Required Path to Resolution
In Florida, before a workers' compensation case can go to a final hearing, it must go through mediation. Mediation is a mandatory settlement conference designed to allow both sides to resolve the dispute without requiring a formal trial.
How mediation works
You, your attorney, the insurance company's lawyer, and an insurance adjuster will meet with a neutral third party called a mediator. The mediator is a trained professional whose job is to facilitate communication and help both sides find common ground. The entire process is confidential.
During mediation, your attorney will present the strengths of your case, using the evidence gathered during discovery. The insurance company will present their defense. The mediator will then go between the two parties, discussing the risks and benefits of continuing to litigate, and trying to broker a settlement agreement that is acceptable to both you and the insurer. A large percentage of denied claims are successfully resolved at this stage.
The Final Hearing: If No Settlement is Reached
If you and the insurance company cannot reach an agreement at mediation, your case will be scheduled for a final hearing before a Judge of Compensation Claims. This is the workers' compensation equivalent of a trial.
At the hearing, your attorney will present all the evidence, and witnesses will testify under oath. The insurance company's lawyer will do the same. After hearing all the evidence, the judge will issue a final, binding order that either grants or denies the benefits you are seeking.
Why Choose Rosenthal, Levy, Simon, & Sosa as Your Workers' Comp Lawyer?
When your workers' compensation claim is denied, you are no longer just an injured worker; you are a litigant in a formal legal dispute against a powerful insurance company. You need a legal team with the experience and resources to effectively challenge that denial.
Experience with workers' compensation law
Our attorneys have a deep knowledge of Florida's complex workers' compensation system. We are familiar with the procedures, the judges, and the common tactics insurance companies use to deny valid claims. This specific focus allows us to build a strategic, effective case on your behalf.
Resources to take on large insurers
Insurance companies have teams of lawyers and substantial financial resources. We level the playing field. Our firm has the resources to hire necessary medical experts, conduct thorough depositions, and see a case through to a final hearing if a fair settlement is not offered.
Local knowledge of the system
With offices in West Palm Beach and Port St. Lucie, we are deeply familiar with the local workers' compensation system. We regularly appear before the Judges of Compensation Claims in our district and have established relationships with the mediators who handle these cases. This local presence is a significant advantage.
AI Is Not Your Advocate in a Legal Dispute
An AI chatbot can tell you the definition of a Petition for Benefits. It cannot, however, cross-examine an insurance company's doctor during a deposition to expose the flaws in their medical opinion.
It cannot evaluate a settlement offer at mediation based on recent rulings by a specific local judge. Relying on AI for guidance when your claim has been denied means you are entering a legal battle without a real advocate.
The appeals process is a strategic, human-driven endeavor that requires the skill and experience of a qualified legal professional.
FAQ for a Denied Workers' Comp Claim
Do I have to pay a lawyer to appeal my denied claim?
No. Workers' compensation attorneys in Florida work on a contingency fee basis. This means you do not pay any upfront costs or fees. The attorney's fee is a percentage of the benefits they successfully recover for you, and that fee is set and approved by the judge according to a statutory formula. If you do not win, you do not owe an attorney's fee.
How long does the workers' compensation appeals process take?
The timeline can vary significantly. From the filing of the PFB to a mediation conference can take several months. If the case does not settle at mediation, it can take several more months to get a date for a final hearing. The complexity of your case and the court's schedule are the main factors.
Can my employer fire me for appealing a denied claim?
It is illegal for your employer to retaliate against you for pursuing a workers' compensation claim. According to the official Florida Division of Workers' Compensation guidelines, this includes firing, demoting, or otherwise discriminating against you for filing a PFB and appealing a denial.
The insurance company denied my claim but still pays for some medical care. Why?
Sometimes an insurer will "pay and investigate." They may cover initial treatment while they investigate the claim. If they later deny it, they will stop paying. It is important not to take their initial payments as an admission that your claim is accepted.
Take Action to Protect Your Right to Benefits
A denied claim is a serious challenge, but it is one you can fight. The workers' compensation system has a clear process for appealing these decisions, but it requires you to take formal action.
You do not have to accept the insurance company's "no" as the final answer.
By securing capable legal assistance, you can ensure that your appeal is filed correctly and that a strong case is built on your behalf. This lets you focus on your recovery while a professional team handles the legal battle.
The attorneys at Rosenthal, Levy, Simon, & Sosa provide strong, capable representation to injured workers whose claims have been denied. We work to challenge unfair denials and pursue the full benefits our clients are due.
Call our office at (866)-640-7117 for a confidential consultation or visit our contact page to schedule a meeting.