What Happens If My Claim is Denied?

If your claim is denied, in full or in part, and you believe that you should receive benefits (or further benefits), your dispute may be handled through a formal hearing or through an informal alternative dispute resolution process.

If you have not retained an attorney, your claim will initially follow the informal process. Your claim will be referred to a specialist in the Division’s Alternative Dispute Resolution (ADR) Unit. The ADR staff will review your claim to determine the issues in dispute and assure that the medical information submitted supports your claim for benefits. If the ADR staff believes that the issues can be resolved without a formal hearing, you and the insurer will be contacted in an attempt to resolve your dispute.

If the issues cannot be resolved through the informal alternative dispute process, you may request a formal hearing with an Administrative Law Judge (ALJ). To request a hearing, you will need to complete an application for hearing form and provide medical information to support your claim. While it is not a requirement, many people believe that it is beneficial to have an attorney involved in the hearing since it is a legal proceeding.

As a legally binding procedure, the ALJ is required to obtain information from all parties during the hearing. The ALJ reviews all pertinent information related to the hearing and issues a decision based on his/her findings. This decision by the ALJ becomes a formal "order" to which the parties of the hearing must adhere. The order specifies the conditions under which the dispute will be resolved.

You may appeal a decision by an ALJ if you believe the decision was incorrect. Your appeal would be made to the Labor and Industry Review Commission (LIRC). Your case would be reviewed by LIRC and they will provide you with a decision. If you disagree with the decision from LIRC, you may appeal to circuit court.