A denial is not the end of your case. In New York it is the start of a process that ends in front of a judge rather than an insurance adjuster — and one with deadlines that belong to the insurance carrier as well as to you.
But it is also a process that can stall silently if nobody is pushing it. What you do in the next few weeks matters more than what the denial letter says.
What a denial actually is
When a carrier disputes your claim it does not simply refuse to pay. It formally contests the claim with the Workers’ Compensation Board. The word you will see is that your case has been “controverted.” While a case is controverted no comp checks are going out, but short-term disability benefits can fill part of the gap in the meantime.
That filing is made electronically now, through the Board’s eClaims system — a FROI-04 transaction, which replaced the paper Form C-7 carriers used for years. The Board then generates the notice that arrives in your mail.
The carrier has two separate deadlines here, and they are commonly confused. It must tell the Board it is not paying by the eighteenth day after your disability began, or within ten days after your employer learned of the accident, whichever period is longer. Separately, its notice of controversy must be filed within 25 days of the date the Board mailed the notice that your case had been indexed.
If the carrier misses the 25-day deadline, it can lose three specific defenses: that you were not its insured’s employee, that you did not sustain an accidental injury, and that the injury did not arise out of and in the course of your employment. That is meaningful — but it is not the whole case. Degree of disability, whether particular body parts are causally related, late notice and late filing are all still open to the carrier. A late denial does not mean you automatically win.
What happens to your medical treatment
This is what almost everyone asks first, and the answer has two halves. Read both of them — the second one is the part that costs people money.
While your case is controverted, the insurance carrier will not pay for your medical treatment.
This is not a delay in processing. Until the carrier accepts your claim, or a Workers’ Compensation Law Judge issues a decision in your favor, it has no obligation to pay a single bill. The Board says the same thing plainly: where a claim is controverted, the insurer does not have to pay indemnity or medical benefits.
In an established claim, your medical care is covered — for life
Once a claim is accepted or won, workers’ compensation generally pays for necessary medical treatment for that work-related injury or illness for the rest of your life. You do not pay for that care; the insurer does. Three conditions come with it, and each of them matters: the treatment has to be authorized, it has to be related to the work injury, and your claim has to stay open. Care that falls outside those lines is not covered.
But that protection depends on the claim succeeding
If the Board ultimately finds that your workers’ compensation claim is not valid, you will be responsible for those costs. This is the real risk you are carrying while the case is contested. It is not that the bills are unpayable today — it is that if the claim fails, they become yours.
So use your private health insurance if you have it
This is the single most useful thing you can do while your claim is disputed. Put the treatment through your own health coverage and let the insurance companies fight it out between themselves.
If your comp claim is later accepted, your health insurer will notify the workers’ compensation carrier and ask to be repaid for what it covered. That is a dispute between two insurance companies rather than a problem of yours. And if the claim does not succeed, you are far better off having had the treatment covered than holding the bills yourself.
Tell your health insurer plainly that this is a disputed work injury. Do not describe it as anything else.
If you do not have health insurance: a doctor who will treat on a lien
Some physicians will treat an injured worker on a lien: they hold the bill and are paid when the claim is accepted or won. Not every doctor does this. Finding one is usually easier through an attorney who knows which providers in your area will.
Either way, do not stop treating
The reason is your recovery, not your file. An injury does not wait for the Board, and time lost out of treatment while a claim is being fought is hard to make up. Keep going, keep every bill, and keep every denial letter — your medical records are also what your claim is built on.
The deadline that gets missed most
Nearly every deadline in a denied claim counts from something other than the day you were hurt. Getting the trigger wrong is how good claims are lost.
| Deadline | How long | Counted from — read this column |
|---|---|---|
| Notice to your employer | 30 days | The date of the accident. Written notice. Limited exceptions exist. |
| Filing your claim | 2 years | The accident — or, for an occupational disease, from disablement and from when you knew or should have known it came from your work. |
| Carrier’s notice that it is not paying | 18 days, or 10 days, whichever is longer | Eighteen days after disability began, or ten days after the employer learned of the accident. |
| Carrier’s notice of controversy | 25 days | The date the Board MAILED the notice that your case was indexed — not the date of your accident. |
| Appeal a Judge’s decision (RB-89) | 30 days | The FILING date of the decision — and the Board must RECEIVE your application by then. |
| Appeal a Board Panel decision | 30 days | The date the Board decision was SERVED on the parties — a different trigger from the one above. |
Two of those deserve saying out loud. Your 30 days to appeal a judge’s decision runs from the filing date of that decision — and the Board treats your application as filed on the day it actually receives it, not the day you mailed it. Putting it in the post on day 30 is late. The 30 days to go to the Appellate Division runs from a different event again: service of the Board panel’s decision on the parties.
The 30-day notice and two-year filing deadlines do have limited exceptions — where the employer already knew about the accident, where it was not prejudiced, where an advance payment was made, where the condition is an occupational disease, or where the injured person is a minor or lacks capacity. Objections can also be waived if the carrier does not raise them at the first hearing. None of that is something to rely on. Assume the deadline is the deadline, and get advice quickly if you think you have missed one.
Why claims get denied
The reasons carriers commonly give fall into a few groups:
- The injury was not work-related — it happened elsewhere, or it is a pre-existing condition rather than a new injury.
- There is no medical evidence connecting the injury to the job. This is about paperwork as often as it is about medicine.
- Notice was late — the employer says it was not told in time.
- The claim was filed too late.
- You were not an employee — the carrier argues you were an independent contractor.
- The accident did not happen the way you describe, or did not happen in the course of employment.
Several of these are arguments about what is in the file rather than about what happened to you — which means they can be answered by putting something better in the file.
Your file needs a medical report, or nothing happens
This is the part that catches people, and it is the reason a denied claim can sit for months with no hearing date.
The Board schedules a pre-hearing conference when two things are in the file: the carrier’s notice of controversy, and a medical report that references your injury. Both. There is even a specific denial code the carrier uses when it believes the medical report on your side fails to reference an injury.
If that medical report is missing, no conference is scheduled and your case does not move. Nobody writes to tell you. The file simply sits.
In practice the report needs to do more than mention your injury. It needs to connect that injury to your work accident, and to cover each body part you are claiming. A report that describes a shoulder problem without saying it came from the accident is the gap most denials are built on.
Do not file a Form RFA-1W
Form RFA-1W is called “Request for Assistance by Injured Worker” — which makes it sound like exactly what you want when a claim has been denied. It is not. The Board is explicit that it is for claims the insurer has already accepted: benefits stopped, a payment is late, treatment was not authorized. It says specifically that it should not be used for controverted claims, or claims the insurer has not yet accepted. The online version, ERFA-1W, is the same form.
On a controverted claim you do not request a hearing — the Board schedules one once the notice of controversy and a qualifying medical report are both in the file. What your case needs is that medical report, not that form.
What the hearing process looks like
Once both pieces are in, the Board schedules a pre-hearing conference as soon as practicable, and in any event within 30 calendar days of receiving them.
The conference exists to work out what is actually in dispute: which issues are contested, what evidence is missing, who the witnesses are, and what the parties can simply agree. A pre-hearing conference statement, Form PH-16.2, is filed ahead of it — ten days ahead. Where you are not represented, the carrier files it. Where the parties are represented, the represented parties file.
That deadline bites hardest on the carrier: an insurance carrier that fails to serve and file its statement on time waives its defenses to the claim. If your own attorney files late, the consequence falls on the attorney — a mandatory and substantial reduction in the legal fee — not on you. Your claim is not forfeited because your lawyer missed a filing.
Hearings are available virtually statewide, and most are held that way. If you are represented, you and any lay witnesses are required to appear by video with your face fully visible on screen, so a working camera and a quiet room are not optional. Unrepresented workers who do not have the technology may be permitted to appear by telephone.
If the judge rules against you
A Workers’ Compensation Law Judge’s decision is not the last word. New York gives you a full appeal ladder, and each rung has its own deadline and its own trigger.
| Stage | What gets filed | Deadline |
|---|---|---|
| Judge rules against you | Application for Board Review (Form RB-89) | 30 days from the filing date of the decision |
| Board Panel rules against you | Application for Reconsideration / Full Board Review (Form RB-89.2) | Optional — does NOT pause the clock below |
| Board Panel decision stands | Notice of Appeal to the Appellate Division, Third Department | 30 days from service of the Board decision |
| Appellate Division rules against you | Application to the NY Court of Appeals | Largely by permission, under the CPLR |
An appeal to the Board goes to a three-member panel, which can agree with the judge, modify part of the decision, reverse it, rescind it, or send the case back for more hearings.
From a Board panel decision you have two possible routes, and depending on the circumstances of your case you may take either or both: you can ask the Full Board to review the panel’s decision on Form RB-89.2, and you can appeal to the State of New York Supreme Court, Appellate Division, Third Department.
Here is the part that costs people their cases. An appeal to the Appellate Division must be taken within 30 days after the Board panel’s decision has been served on the parties — and applying for Full Board Review does not stop that clock or extend it. If you file for Full Board Review and let those 30 days run, the appeal to the Appellate Division is gone, however strong it was.
If you are considering Full Board Review, calendar the Appellate Division deadline at the same time. They run together, not one after the other.
Appeals to the Third Department are e-filed through NYSCEF, mandatory for most appellants since 1 January 2023, though self-represented parties may be exempt. Beyond that, review by the Court of Appeals is largely a matter of permission rather than a right.
Four things to do this week
1. Check that a medical report referencing your injury is actually in the file
Without it, nothing is scheduled and nothing happens. This is the single highest-value thing to confirm.
2. Find the date on the Board’s indexing notice
Not the date on the denial. The carrier’s 25-day clock runs from the Board’s notice.
3. Sort out treatment now, not later
Health insurance or a lien arrangement. Do not let the case go quiet while you wait.
4. Write down every deadline and what it counts from
Thirty days from a judge’s decision, received not mailed. Thirty days from service of a Board decision. Ten days before a conference. Nobody will remind you.
Frequently asked questions
Does a denial mean my claim is over?
No. A controverted claim goes before a Workers’ Compensation Law Judge who decides it after hearing both sides. The carrier’s denial is a position, not a ruling.
The carrier missed its deadline. Do I win?
Not automatically. A carrier that files its notice of controversy late can lose three specific defenses — that you were not an employee, that you had no accidental injury, and that the injury did not arise out of and in the course of employment. Other issues, including how disabled you are and whether particular body parts are related, remain open.
How long does a denied claim take?
It depends on how many issues are contested, whether depositions are needed, and how fast the medical evidence is assembled. A case turning on one narrow issue moves faster than one contesting both the accident and the injury.
What if I missed the 30-day appeal deadline?
Speak to an attorney immediately rather than assuming nothing can be done. There is limited discretion in some circumstances, but it is narrow and it shrinks with time.
Do I need a lawyer for a denied claim?
You are not required to have one. But a controverted claim is a contested legal proceeding — filing deadlines, evidentiary requirements, sworn testimony — against a carrier represented by counsel who does this every day. Fees in workers’ compensation are approved by the Board and come out of the award, generally fifteen percent of the new money awarded, so there is nothing to pay up front and nothing owed if there is no recovery.
What comes after a claim is established
Winning a controverted claim is not usually the end of the case. Once a claim is established, the questions that follow are what your injury is worth and whether to settle. A Schedule Loss of Use award compensates permanent loss of function in a limb; a Section 32 settlement is a negotiated end to the case, and once approved it is generally final. Both are worth understanding before anyone asks you to agree to anything.
Talk to a New York workers’ compensation attorney
If your claim has been denied, clocks are already running — on the medical evidence, on the conference, and on any appeal. The sooner someone looks at the file, the more options are still open.
The Law Offices of Frank J. Dito, Jr. represents injured workers throughout Staten Island and Brooklyn. Consultations are free. If we don’t recover money for you, we don’t get paid.
Call 718.701.2776 or 800.310.5520
1610 Richmond Road #200, Staten Island, NY 10304
Before the appeal stage, there is the hearing itself. Our page on what happens at your workers’ comp hearing covers the pre-hearing conference, testifying on camera, and how decisions are issued.
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