Getting a denial letter when you are injured, in pain, and unable to work is devastating. But here is what most people do not know: denials are extremely common, and they are not the final word. Insurance companies deny claims as a strategy. They know that many workers will simply give up. Do not be one of them. Georgia law provides a clear process for challenging a denial, and workers who fight back with experienced legal help often win. Attorney Jodi Ginsberg has spent over 30 years helping denied workers get the benefits they were owed all along.
Common Reasons Workers Comp Claims Get Denied
Insurance companies use a variety of reasons to deny claims. Some are legitimate. Many are not. Understanding why your claim was denied is the first step in building your response.
The employer disputes the injury was work-related. This is the most common denial. The insurer may argue that the injury happened outside of work, or that there is no evidence connecting it to your job duties.
The insurer blames a pre-existing condition. If you have any prior medical history involving the same body part, the insurer may claim your current problems are from the old condition, not the work injury. Georgia law protects you here, as long as the work injury aggravated or worsened the condition.
You failed to report the injury within 30 days. Late reporting does not automatically disqualify you, but it gives the insurer a strong argument to deny.
You did not file Form WC-14 within one year. Missing the statute of limitations is much harder to overcome. In most cases, it ends your claim permanently.
The insurer alleges willful misconduct or intoxication. If the employer claims you were drunk, on drugs, or engaged in horseplay at the time of injury, they may deny your claim on that basis.
The employer claims you are an independent contractor, not an employee. If you are classified as a contractor, you may not be covered. However, misclassification is common. Just because the employer calls you a contractor does not mean you legally are one.
The insurer disputes the severity or extent of the injury. They may acknowledge the injury happened but argue it is not as serious as your doctor says, or that you have already recovered.
What Does Controverted Mean?
When an insurance company denies your claim, they file what is called a controversion. This is Section C of Form WC-1, and it must state the specific reasons why they are refusing to pay benefits.
The controversion is not just a vague rejection. The insurer is required to list specific legal grounds. This matters because it tells you and your attorney exactly what arguments they are making, which allows you to build a targeted response.
If you receive notice that your claim has been controverted, do not ignore it. This is the point where legal representation becomes critical.
The Hearing Process Before an Administrative Law Judge
If your claim is denied, you have the right to request a hearing before the State Board of Workers Compensation. This hearing takes place before an administrative law judge (ALJ), and it functions like a mini-trial.
Before the hearing, both sides go through a discovery phase. This includes gathering medical records, taking depositions (sworn testimony from witnesses, doctors, and you), and compiling evidence.
At the hearing itself, both sides present their case. Your attorney introduces your medical evidence, testimony, and arguments for why you are entitled to benefits. The insurance company presents their side. The ALJ hears everything and issues a written decision.
Hearings typically take several hours. Having an experienced attorney who knows the ALJs, understands the evidentiary standards, and can cross-examine the insurance company witnesses makes a significant difference in outcomes.
The ALJ decision is not the final step. If either side disagrees, there is an appeals process.
The Appeals Process in Georgia Workers Comp
Georgia workers comp has a structured appeals ladder. Each level has its own rules and deadlines.
Level 1: The ALJ issues an initial decision at the SBWC. This is where most cases are resolved.
Level 2: Either side can appeal to the Appellate Division of the State Board of Workers Compensation. The Appellate Division reviews the record from the ALJ hearing and can affirm, reverse, or modify the decision.
Level 3: From the Appellate Division, you can appeal to the Superior Court of the county where the injury occurred.
Level 4: The next level is the Georgia Court of Appeals.
Level 5: The final level is the Georgia Supreme Court, which takes cases on a discretionary basis.
Each appeal has strict filing deadlines, usually 20 to 30 days from the prior decision. Missing a deadline means accepting the lower decision as final. Do not attempt the appeals process without experienced legal counsel.
Have questions about your case? Call (770) 351-0801 for a free consultation.
Call NowWhat to Do Right Now If Your Claim Was Denied
If you just received a denial, here are the steps to take immediately.
Do not panic. A denial is a setback, not a dead end. Many denied claims are successfully overturned.
Do not sign anything from the insurance company. They may try to get you to agree to a statement or waiver that hurts your case.
Preserve all documents. Keep every letter, email, form, and notice related to your injury and your claim. Organize them by date.
Gather your medical records. Request copies of all treatment records, diagnostic reports, and doctor notes related to your work injury.
Do not post about your case on social media. Anything you share online can and will be used against you.
Call an experienced workers comp attorney immediately. Time limits apply to every stage of the dispute process. The sooner you get help, the stronger your position will be.
Attorney Jodi Ginsberg offers free consultations for denied claims. She will review your denial, explain your options, and tell you honestly whether your case has merit. Call (770) 351-0801.