When a Claim is Denied

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

If they have not retained an attorney, their claim will initially follow the informal process. Their 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, the employee may request a formal hearing with an Administrative Law Judge (ALJ).