IF MY CLAIM WAS DENIED
What if I have a disagreement about my benefits?
At some point during your claim, you or the claims administrator might disagree with what your treating physician reports about your injury or treatment. When there is a disagreement, you may be evaluated by a qualified medical evaluator (QME). To qualify as a QME, a physician must meet additional educational and licensing requirements. This includes passing a test and participating in ongoing education on the workers' compensation evaluation process.
If you have an attorney, your attorney and your claims administrator might opt instead to agree on a doctor to resolve medical disputes, which often leads to a quicker resolution of your case. This doctor is called an agreed medical evaluator (AME).
I want to object to the denial of my claim:
If you want to object to the denial of your claim, you will need to file a case at one the DWC's 24 offices located around the state. Each DWC office has a trial court where disputes that arise from Workers’ Compensation claims are decided by a judge without a jury.
How do I file a case?
To have your case heard by a judge, you must first file an Application for Adjudication of Claim. You must file the application at the DWC office in the county where you live or in the county where you were injured. You must serve the application on all other parties involved, which generally includes the claims administrator.
What happens next?
The DWC office where you filed the application will send you a notice confirming that it has been filed. The notice will include your assigned case number, which will begin with the letters “ADJ” followed by a sequence of numbers. Keep this notice and use the assigned case number on all documents and correspondence relating to your case.
How do I get a hearing before a judge?
You must file a Declaration of Readiness to Proceed to request a hearing. Upon filing, the DWC will then schedule your case for a hearing called a mandatory settlement conference (MSC).
What happens at the hearing?
You and your claims administrator or their attorney will appear before a judge. The judge will discuss the case with both of you and try to assist in reaching a settlement. If your case is not settled at the MSC, you will need to prepare documents that outline the dispute, identify the items each party will present at trial, and produce the names of the witnesses that each party will ask to testify. The judge will then schedule a date for trial.
The trial will be held before a judge who will decide the law and facts in dispute in the case. You must attend the trial. The judge will issue a written decision after the trial and send it to you by mail, which usually occurs between 30 and 90 days after the trial. If either you or the claims adjustor disagrees with the judge’s decision, you can file a Petition for Reconsideration.