Workers’ Comp Denials and Appeals in Wisconsin

The Short Answer:

According to the Wisconsin Worker’s Compensation Dashboard, over 77% of workers’ initial compensation claims are approved while approximately 22% of claims are unsuccessful. Whether you’re applying for benefits or have already received a workers’ comp denial, here’s what you need to know about the appeals process and how to give yourself the best chances for a successful claim.

Key Takeaways

• More than 2 out of 3 workers’ comp claims in Wisconsin are approved, but 22% are denied.
• Up to 3,000 injured workers file workers’ compensation appeals annually.
• Incomplete evidence and disputes about the injury are common reasons for denials.
• Meeting deadlines and providing adequate evidence can reduce the risk of a denial.
• The state offers multiple levels of administrative and judicial appeals.
• Deadlines vary depending on the type of appeal you’re filing.
• If you’re filing a formal appeal, consult an attorney to ensure the best outcome.

Top Reasons for Workers’ Comp Claim Denials in Wisconsin

While many workers’ compensation claims are processed without problems, insurance companies often look for reasons to deny claims or minimize benefits. Even minor errors or missing details can lead to a rejection. Here are a few of the most common reasons for workers’ comp denials in Wisconsin.

1. Missed Deadlines

Failing to meet state-mandated deadlines for reporting your injury can disqualify your claim.

Tip: Notify your employer in writing immediately after the accident or as soon as possible. Delays give insurers more room to claim that your injury is not work-related.

2. Disputes About the Injury

Insurance companies may deny your claim unless you can show that your injury occurred during the normal course of your job. Your employer may claim:

• The injury happened off-duty or while you were on break.
• The injury was caused by horseplay, misconduct, or reckless behavior.
• The condition was pre-existing and was not aggravated by your employment.

Tip: To qualify for workers’ comp, you must prove that the injury or illness occurred while doing your job. Witness statements, medical records, and photos or videos can help to prove when and how your injury occurred.

3. You Left Your Job Before Filing

If you quit or were terminated or laid off before you filed for workers’ compensation, it can be more difficult to prove that your injuries are work-related. Insurers may try to argue that you’re only filing an injury claim to retaliate against your employer. Your chances of a successful outcome may be higher if you reported your injury but the claim was not resolved before you left. You may wish to consult a Wisconsin workers’ compensation attorney if you believe that your employer fired you in retaliation for your injury.

4. Insufficient Evidence or Errors

Incomplete, inaccurate, or inconsistent records, especially discrepancies between your medical records and accident report, are a frequent reason for denial. Keep records of all relevant documents. You may need them to appeal a denial or reopen your claim if you return to work but are later reinjured. This includes:

• Medical records.
• Test results.
• Doctor’s notes.
• Accident reports.
• Time-off records.
• Paystubs or tax returns.
• Communication with your employer.
• Insurance correspondence.
• Benefits statements.

5. Failure to Follow Medical Advice

Delays in medical care can negatively affect the outcome of your claim. It’s imperative to follow all medical advice. Do not miss follow-up appointments or ignore medical restrictions. Insurance companies may claim that you’re exaggerating your injuries or prolonging your recovery time if you miss follow-up visits. They may even hire private investigators to keep track of claimants and prevent fraud.

Tip: Provide a copy of any medical restrictions to your employer and workers’ comp provider, so they’re aware of your limitations.

How to Appeal a Workers’ Comp Denial in Wisconsin

If your workers’ claim is denied, you will receive a letter explaining why. You should receive this notice within 14 days of reporting your injury. An initial denial does not always mean that you’re ineligible. Over 3,000 injured workers request hearings in Wisconsin annually, and many workers recover benefits on appeal. Here’s what to expect during the appeals process.

Step 1: Informal Dispute Resolution

If your workers’ compensation claim was denied due to missing or incomplete documentation, you may be able to resolve it by providing additional evidence to the insurer. Alternatively, you may be able to request an informal hearing where a specialist from the DWD’s Division of Workers Compensation Dispute Resolution Section will review your claim.

Deadlines: The official deadline to file a workers’ comp appeal is 6 years from the date of the injury or your last payment or within 12 years of developing an occupational illness. For best results, file an appeal as soon as possible.

Step 2: Request a Hearing With an Administrative Law Judge (ALJ)

If you cannot resolve your workers’ comp denial informally, your attorney can request a formal hearing before an administrative law judge. The ALJ will review evidence and hear testimony from you, your employer or the employer’s insurance company, and any witnesses, including co-workers or medical experts.

Step 3: Appeal to the Labor and Industry Review Commission (LIRC)

Your attorney has just 21 days from the ALJ’s decision to file a petition with the LIRC. The Commission may affirm, reverse, or modify the ALJ’s ruling, or your case may be sent back to an ALJ for a new hearing.

Step 4: Appeal to the Wisconsin Circuit Court

The next step is to appeal administrative decisions through a judicial review. Your attorney must request an appeal within 30 days after the LIRC’s decision. No new evidence can be presented during these appeals. The court’s primary goal is to determine if the LIRC made a procedural error. The LIRC’s ruling may be affirmed or reversed, or your case may be remanded to the LIRC for further hearings.

Step 5: Appeal to the Wisconsin Court of Appeals or Supreme Court

Although very rare, complex cases are sometimes heard by the state’s highest appeals courts. These cases typically involve significant procedural errors or questions about the interpretation of state laws.

What Are My Chances of Winning a Workers’ Comp Appeal?

Data on the outcome of high-level appeals is limited since many cases are remanded before a final decision is reached. Successful appeals typically have clear, convincing medical evidence that’s provided within applicable deadlines. Hiring an experienced Wisconsin workers’ compensation lawyer can also increase your chances of success. Here’s some current data on the frequency of workers’ comp appeals in Wisconsin.

Source: https://doa.wi.gov/Pages/LicensesHearings/WCStatistics.aspx

How Long Does a Workers’ Comp Appeal Take?

The length of a workers’ compensation appeal in Wisconsin varies depending on the type of appeal, the complexity of the case, and how quickly required documents are submitted. Some cases are resolved in several weeks, while others can take more than a year to complete.

• Alternative Dispute Resolution: Several weeks or months
• ALJ Hearings: 3-6 months on average, depending on case loads
• Judicial Appeals: Up to 1-2 years for complex cases

Do I Need a Workers’ Comp Denial Lawyer?

While you do not need to hire a workers’ compensation lawyer just because you’re injured on the job, you may benefit from legal representation if your claim has been delayed, denied, or disputed. You should strongly consider hiring an attorney if:

• Your claim was denied for insufficient evidence.
• Your employer disputes your claim.
• You missed deadlines but have valid reasons.
• Your injury is severe or disabling.
• You faced retaliation or termination.
• You’ve been accused of misconduct.
• You’re attempting secondary appeals.
• The insurer has made a low-ball settlement offer.

Working with an attorney can help to simplify the appeals process. Your lawyer can explain your rights and ensure that paperwork is submitted correctly and on time. Convincing evidence that’s presented effectively can dramatically increase your odds of recovering the workers’ compensation benefits that you need.

Get Help With Your Workers’ Comp Appeal

At Sam Bomier Law LLC, our workers’ compensation lawyers have over 38 years of experience fighting for injured workers in the Fox Cities and throughout Northeast Wisconsin. If your claim was denied, don’t give up, and don’t navigate the appeals process alone. Contact us today for a free case evaluation.