If your workers’ comp claim has been denied, or you have a dispute with the insurance company about your benefits, you can challenge the decision with the New Mexico Workers’ Compensation Administration (WCA). (For an overview of eligibility and benefits, see our article on filing a workers’ comp claim in New Mexico.)
If you would like assistance trying to resolve the dispute informally, you can contact the New Mexico WCA Ombudsman Program. An ombudsman is a representative from the workers’ comp agency who can answer your questions and try to help you resolve minor disputes with the insurance company.
If you’re not able to resolve the dispute with the insurance company directly, or with the help of an ombudsman, you’ll need to file a complaint with the WCA Court Clerk. To do so, you must file a complaint form and a summonswith the court clerk and mail a copy to the insurance company. You must file your complaint within one year of the insurance company’s refusal to pay your benefits.
In addition to filing a complaint, you will need to give a form to your doctor to fill out (Form Letter to Health Care Provider). Your doctor must complete the form—which asks about your injury, treatment, and continuing limitations—and return it to the WCA Court Clerk.
Once the WCA receives your complaint, your case will be scheduled for a mediation conference. A mediation is an informal meeting, where a neutral third party from the WCA (called a “mediator”) will try to help you and the insurance company reach an agreement. You should bring copies of documents that your support your case, including medical records, witness statements, unpaid medical bills, and wage records. The mediator will review these documents and ask you questions about your claim.
If you and the insurance company agree on a resolution, the mediator will write up the terms of the agreement. If you cannot agree, the mediator will make his or her own recommendation as to how the dispute should be resolved. Either party may reject the recommended resolution within 30 days. Otherwise, the recommendation becomes a binding court order.
If either you or the insurance company rejects the mediator’s recommendation, you will continue on to a formal hearing before a workers’ comp judge. Hearings usually take place within a few months of filing a complaint. You will receive a written notice in the mail, with the time and place of the hearing, at least 20 days in advance.
At the hearing, both sides will have an opportunity to submit documents, present testimony from witnesses, and make legal arguments. The judge will review the evidence and mail a written decision after the hearing.
Unlike in many other states, the New Mexico workers’ compensation agency does not provide a second level of administrative review. Instead, if you are unhappy with the judge's decision, you must file an appeal with the New Mexico Court of Appeals within 30 days of the judge’s order.
While it’s not a requirement, most workers with contested workers’ compensation cases hire lawyers to represent them in the appeals process. The appeals process requires detailed knowledge of workers’ compensation law and procedural rules, especially when it comes to presenting your case at a workers’ compensation hearing. Having a lawyer on your side can greatly increase your odds of success. For help finding a workers’ compensation lawyer, check out our online lawyer directory.