Workers’ Compensation Claim Denial

An injured worker, or surviving spouse and/or dependents in cases of death, may challenge the employer/insurer’s claim denial by filing an Application for Hearing. There is a different form depending on whether the claim is for an injury by accident or for an occupational disease. There are also separate forms for death claims, depending on whether the death was due to an accident or was the result of occupational disease.

Along with the Application for Hearing, the following forms need to be filed:

• Medical Treatment Provider List
• Authorization to Disclose, Release and Use Protected Health Information
• Summary of Medical Records form or copies of medical records supporting the claim

These forms can be filed in person, by mail, by fax or by e-mail with the Adjudication Division. The employer and the correct insurance carrier, unless the employer is self-insured, must be identified on the Application for Hearing.  Use the Workers’ Compensation Coverage Verification system in the services tab above if you are unable to identify the insurance carrier(s) for the date of injury or period(s) of occupational exposure (disease claim). Incomplete forms will be returned with no action taken.