Process Stage 6 of 12

My NY Workers' Comp Claim Was Denied — What Now?

Your claim has been denied or controverted — the carrier filed a FROI-04 (or an RFA-2 contesting an issue), and the case is now a litigation matter. Most denials are not as final as they look. NY workers' comp denials fall into a small number of categories — late notice, no causation, course-of-employment dispute, classification dispute, AWW dispute, statute, no insurance, undocumented worker — and each category has a specific response framework. The Denial Analyzer tool walks through the categories and helps you identify which one applies.

Denials are categories, not verdicts. Identify the category, build the response, request the hearing.

What's happening

The carrier has formally taken the position that your claim is not compensable, or that a specific issue (causation, AWW, classification) should be decided against you. The case is open at the WCB but adversarial. A hearing before a Workers' Compensation Law Judge will resolve the contested issues. Indemnity benefits are typically not paid pending the resolution unless a separate accommodation was made. Treatment is also at risk — controverted cases sometimes see medical authorizations slow or stop.

What comes next

  1. Identify the denial type. Run the Denial Analyzer to categorize the denial and see how beatable each category is under NY law. Common categories: late notice (often excused), no causation (medical evidence), classification, AWW dispute, statute, no insurance, course-of-employment.
  2. Get the FROI-04 or RFA-2 from the eCase docket. The carrier's filing states the legal basis for the denial. Read it carefully — sometimes the stated basis is narrower (or broader) than the visible facts.
  3. Build the medical foundation. Most denials require medical evidence to overcome — a treating physician's narrative on causation, an IME counter-report, prior records contradicting the carrier's theory.
  4. Request a hearing. The contested issue must be set for hearing before a Workers' Compensation Law Judge. The judge will rule on the specific issue (causation, AWW, etc.) on the record.
  5. Don't let medical stop. Even if the carrier refuses to authorize treatment, find a way to keep documenting. Lapses in treatment during a controversion period are routinely used against the claimant later.

Common pitfalls at this stage

  • Accepting the denial without challenge. Many viable claims die because the worker assumed the denial was final. Most denials are challengeable; some are highly beatable.
  • Missing hearing notices. Hearings have dates. Failure to appear is fatal.
  • Trying to fix the denial with a letter. Carriers do not reverse denials based on letters from claimants. The path is the hearing and the evidence.
  • Going to hearing unrepresented on a contested issue. Defense counsel is professional and prepared. Causation, AWW, and classification disputes are technical. Unrepresented claimants lose hearings they should win.
  • Not collecting the records that disprove the denial. Late-notice denials are often defeated by showing the employer had actual knowledge — incident reports, supervisor testimony, prior medical visits referencing the work injury.

Tools, FAQs, and pages relevant to this stage

When to call now

Immediately. Denied claims have hearing deadlines, and the case will not get better with time. Defense counsel is professional and the technical issues — causation, late notice, AWW, classification — reward representation.

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Attorney Advertising — Educational Use Only. This page provides general information about New York workers' compensation. It is not legal advice and does not create an attorney-client relationship. Every case turns on its facts. For analysis of your matter, contact Levi directly.

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