Indiana Workers’ Comp Medical Denials: How to Appeal

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

If you were hurt at work in Indiana, your medical care is generally your employer’s responsibility under workers’ compensation, not your health plan’s. When the employer or its insurance carrier won’t approve a treatment, stops paying for care, or leaves a bill unpaid, Indiana has its own way to resolve it. The steps and deadlines are different from health insurance appeals.

This guide explains how to push back on a workers’ comp medical denial in Indiana. It is part of the Coverage & Appeals Center. For health insurance appeals in Indiana, see how to appeal in Indiana.

Who pays for care after a work injury

Indiana law says that after a work injury, the employer must provide an attending physician free of charge to you. It must also provide the services and products the physician or the Board decides are needed (IC 22-3-3-4).

A few more points from the same law:

• The employer picks the doctor. In general, the employer furnishes the attending physician. An employer and its workers can also agree, with Board approval, on which providers will treat.
• Emergencies and other good reasons. If another doctor treats you because of an emergency, because the employer failed to provide care, or for another good reason, the employer pays the reasonable cost. This applies during temporary total disability and needs Board approval.
• No delay in emergency care. The employer or carrier may not delay emergency care that the hospital’s physician says is needed.
• The Board can order treatment. On the application of either side, the Board can require the employer to furnish treatment it finds reasonably necessary (IC 22-3-3-4).

The law also says that, in some situations, refusing treatment the employer provides can stop your compensation while you refuse.

Indiana workers’ comp medical appeals at a glance

The Board’s informal process does not say it pauses the 2-year filing deadline.

Step 1: Ask the Board for informal help

Indiana’s Worker’s Compensation Board has an informal dispute process. It is not called an “ombudsman.” It starts when you file a completed Request for Assistance (State Form 45442) with the Board. A Case Coordinator is assigned and contacts the people involved (WCB: Informal Disputes).

The Board lists the kinds of problems it handles this way. They include:

• Unpaid medical bills.
• Billing injured employees (a provider sending the bill to you).
• Premature termination of medical and disability benefits.
• Delays in paying temporary disability benefits.
• Disagreements about whether the claim is covered.

The Board also offers mediation (WCB: Informal Disputes).

1. Write down the problem. Note what was denied or unpaid, the date, and who told you. Keep any letters from the employer or carrier.
2. Ask the carrier in writing first. Send a short letter asking it to approve the care your attending physician ordered. Use the template below.
3. Get your physician’s support. Ask the treating office for the order and a short note on why the care is needed.
4. File a Request for Assistance. Complete State Form 45442 and file it with the Board (WCB: Informal Disputes). Attach copies, not originals.
5. Work with the Case Coordinator. Answer calls and send what they ask for. Keep a log with dates and names.
6. Watch the 2-year deadline. If the informal process doesn’t fix it, you may need to file a formal claim (IC 22-3-3-3).

If your temporary total disability benefits are ending

If you get a notice that your TTD benefits will end (State Form 38911), you must send a written disagreement within 7 days of getting it. If the Board finds it timely and an independent medical exam (IME) makes sense, you have 21 days to send a response. Then the IME is scheduled (WCB: Informal Disputes).

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Insurance carrier name] — Workers' Compensation Claims
[Address or fax for the claim adjuster]

RE: Request to authorize treatment
Injured worker: [Name]
Employer: [Employer name]
Claim number: [Number]
Date of injury: [Date]
Treatment requested: [Treatment]
Attending physician: [Name, credentials]

Dear [Adjuster name]:

My attending physician, [name], has ordered [treatment] for my work injury. On [date], I was told that this care [was denied / is not approved / will not be paid]. The reason given was: "[exact reason, if any]."

Enclosed are:
- The physician's order and a note explaining why the care is needed
- Medical records from [dates]
- Any letter I received about the denial

Please approve this treatment, or tell me in writing the specific reason it is not approved.

If I do not hear back by [date], I plan to ask the Worker's Compensation Board for help by filing a Request for Assistance.

Sincerely,
[Signature]
[Printed name]

cc: [Employer contact]

Step 2: File a formal claim and appeal

If informal help doesn’t resolve it, the dispute moves forward only when an Application for Adjustment of Claim (State Form 29109) is filed (WCB: Disputed Claims). You can pursue a claim without a lawyer. A corporation must have one.

The deadline is 2 years after the injury. If you were paid temporary total or temporary partial disability benefits, the 2 years runs from the last day that benefit was paid (IC 22-3-3-3). Payments for medical care alone are not listed as restarting it.

1. File the Application for Adjustment of Claim. Use State Form 29109 (Indiana Forms: SF 29109). The Board gives it a cause number.
2. Go to the pre-trial conference or hearing. It is set before a Single Hearing Member. At the hearing, each side presents evidence. The injured worker must prove the injury happened at work (WCB: Disputed Claims).
3. Get the award. The Single Hearing Member prepares and serves a written award on both sides.
4. Ask the Full Board to review. File an Application for Review by Full Board (State Form 1042) within 30 days of the award (IC 22-3-4-7; Indiana Forms: SF 1042).
5. Appeal to the Court of Appeals. Either side can appeal the Full Board’s award within 30 days, for errors of law (IC 22-3-4-8). The Supreme Court of Indiana comes after that (WCB: Disputed Claims).

How workers’ comp and your health plan fit together

Workers’ comp is generally responsible for care for a work injury. Many health plans say they do not cover work injuries. But when a comp claim is denied or still in dispute, it can be unclear who pays in the meantime.

Some general tips:

• Tell every provider it’s a work injury. Give them your claim number and the carrier’s name.
• Keep any denial in writing. Your health plan may ask for it before it looks at the bill.
• Read your health plan’s rules. Look for language about work-related injuries.
• If a provider bills you, tell the Board. “Billing injured employees” is one of the problems its informal process handles (WCB: Informal Disputes).

Hurt in a car crash while working? Indiana requires liability insurance and does not have a no-fault (PIP) system. Medical payments coverage is optional (IDOI: Auto Insurance). See auto injuries and PIP.

An Indiana workers’ comp denial, start to finish

*This is an illustrative example, not a real patient.*

• March 2: Sam, a nurse’s aide in Evansville, hurts her back lifting a patient. The carrier accepts the claim, and the employer’s attending physician starts treatment.
• April 6: The physician orders physical therapy. On April 10, the adjuster tells Sam by phone that therapy is not approved.
• April 13: Sam sends a letter asking the carrier to approve the therapy, with the physician’s order. She asks for any denial in writing.
• April 27: With no answer, Sam files a Request for Assistance (State Form 45442). A Case Coordinator contacts the carrier.
• If that fails: Sam can file an Application for Adjustment of Claim, well within 2 years of her injury.

If a Single Hearing Member later rules against her, Sam would have 30 days to ask the Full Board for review.

Common mistakes

• Treating it like a health insurance appeal. Health plan rules, like the 120-day external review window, don’t apply to workers’ comp.
• Waiting on the phone. Ask for every denial in writing, and send your own requests in writing.
• Missing the 7-day window. If you get a notice that TTD benefits will end, your written disagreement is due within 7 days.
• Assuming informal help stops the clock. The 2-year deadline to file still matters (IC 22-3-3-3).
• Missing the Full Board deadline. Review must be requested within 30 days of the award (IC 22-3-4-7).
• Looking for an “ombudsman.” The Board’s help is called the informal dispute process.

Where to get help

The Board’s informal dispute and disputed claims pages explain the steps and link to the forms (WCB: Informal Disputes; WCB: Disputed Claims).

For a health plan denial that is not a work injury, use the appeal route wizard or the appeal deadline calculator. If you need therapy after a work injury, see getting physical therapy covered. Working in Kentucky? See Kentucky workers’ comp medical appeals.