After you file, an insurance adjuster reviews your claim, not your employer and not a judge. The adjuster pulls medical records, payroll history, and sometimes recorded statements or surveillance, then accepts, denies, or delays the claim within a state deadline that runs anywhere from 14 to 90 days. Approved wage benefits usually pay two-thirds of your average weekly wage, capped at a state maximum.
That is the short version. The details below cover who touches your file, what gets verified, why your check is the exact dollar amount it is, and what the deadlines look like in four states with very different rules.
What happens right after you file a claim
Your claim form goes to your employer, and your employer reports it to its workers’ compensation insurance carrier. In most states the employer also has a short statutory window to file an injury report with the state workers’ compensation agency, which opens a case number on the state side even before the insurer has decided anything.
The carrier assigns a claims adjuster, usually within a few business days. On a straightforward medical-only claim, that adjuster may handle hundreds of open files. On a lost-time claim with surgery or a disputed cause, the file often goes to a senior adjuster with a smaller caseload.
The first thing the adjuster does is compare two documents: your account of the injury and the employer’s first report. Mismatches in the date, time, location, body part, or whether anyone witnessed it are the single most common trigger for a deeper investigation. A claim where both documents say the same thing tends to move quickly.
Federal civilian employees are a separate track entirely. They file under the federal program administered by the U.S. Department of Labor rather than a state system, so the deadlines and benefit formulas below do not apply to them.
What the adjuster actually checks during the investigation
The adjuster is answering three questions: did this injury happen, did it happen at work, and what is it worth. Each question has its own evidence trail.
Medical records. The adjuster requests records from the treating provider and compares the clinical notes against the reported incident. A lumbar strain reported after lifting a pallet should show up in the first visit note as exactly that. When the note says the pain started weeks earlier, or describes a mechanism of injury that does not match the incident report, the claim gets flagged.
Causation versus pre-existing condition. Degenerative findings on imaging are extremely common in adults, so a bulging disc on an MRI does not by itself prove or disprove a work injury. The adjuster looks for prior treatment for the same body part, often through a claims index search that shows previous workers’ comp and liability claims under your name.
Wage records. Payroll pulls the gross earnings for the period the state uses to set your average weekly wage, typically the 52 weeks before the injury. Overtime, shift differentials, and sometimes second-job income can change the figure, which is why this is worth checking against your own pay stubs.
Statements. Recorded statements from you, your supervisor, and any witnesses are standard on lost-time claims. These are transcribed and become part of the file.
Surveillance and social media. These appear in a minority of claims, generally where the injury is subjective, the claimed disability is long, or the reserve on the file is large. The pattern of evidence gathering is similar to how an insurance adjuster reviews a claim in other lines of coverage: verify the loss, verify the cause, verify the amount.
What the adjuster is not doing is assessing fault. Workers’ comp is a no-fault system in every state, so whether you were careless is usually beside the point. The exceptions are narrow, typically intoxication, horseplay, or intentional self-injury, and the insurer has to prove them.
How long the review takes
Typical timeline stage by stage
Reporting to the employer takes a day or two if you do it promptly. The employer’s report to the carrier usually follows within a week. Then the clock the adjuster cares about starts, and in most states that first decision window is somewhere between two weeks and three months.
Accepted claims have a second, separate deadline for money to actually arrive. Several states tie the first indemnity payment to a fixed number of days after the employer learns of the injury rather than to the date of acceptance, which is why a worker in one state may see a check before a worker in another state has even gotten a decision letter.
Nearly every state also has a waiting period, usually three to seven days, before wage benefits start accruing at all. If your disability runs past a second threshold, often 14 days, those waiting-period days get paid retroactively.
How state deadlines differ
The spread between states is wider than most general guides suggest. Four examples:
| State | Insurer must accept or deny | What happens if the deadline passes | First step after a denial |
|---|---|---|---|
| California | 90 days after the DWC-1 claim form is filed | Injury is presumed compensable | Application for Adjudication with the WCAB, generally within 1 year of injury |
| Texas | About 15 days after the injury is reported to the carrier | Carrier must begin paying or explain its dispute | Benefit review conference, then contested case hearing, then Appeals Panel within 15 days of the hearing decision |
| Pennsylvania | 21 days after notice of injury | Insurer exposed to penalties; worker can file a claim petition | Claim petition before a workers’ compensation judge |
| Florida | First payment or denial by the 14th day after the employer receives notice | Late-payment penalties and interest attach | Petition for Benefits |
California’s rule is the most consequential for workers: under Labor Code section 5402, if liability is not rejected within 90 days the injury is presumed compensable, and that presumption can only be rebutted with evidence discovered after the 90-day window closed. Texas sits at the other end, where a carrier such as Texas Mutual states it has 15 days from the report to determine coverage. Pennsylvania’s insurers must issue a notice of compensation payable, a temporary notice, or a denial within 21 days of the injury report. Florida ties the deadline to the money rather than the paperwork: the carrier generally must pay the first installment or deny by the 14th day after the employer gets notice.
The practical decision rule: find your state’s accept-or-deny deadline before you start worrying about silence. In California, silence past day 90 works in your favor. In Pennsylvania or Florida, silence past the deadline is a procedural violation you can raise, not something to wait out.
How your wage-replacement check is calculated
Three numbers produce your weekly check: your average weekly wage, your state’s replacement percentage, and your state’s maximum.
Average weekly wage is usually gross earnings over the 52 weeks before the injury, divided by 52. Most states then pay two-thirds of that figure for temporary total disability. Because the benefit is generally not subject to federal income tax, two-thirds of gross lands much closer to your old take-home pay than it sounds.
Here is the math on a worker earning $900 a week in a two-thirds state:
- Average weekly wage: $900
- Temporary total disability rate: $900 x 0.6667 = $600 per week
- State maximum: not reached, so the full $600 is payable
Now run the same formula on a worker earning $2,500 a week in New York. Two-thirds would be $1,666.67, but the New York Workers’ Compensation Board set the maximum weekly rate at $1,281.50 for injuries from July 1, 2026 through June 30, 2027, with a minimum of $384.45. That worker receives $1,281.50, roughly half of prior earnings rather than two-thirds. The cap is why high earners feel the gap most sharply, and it is set as two-thirds of the statewide average weekly wage, which was $1,922.25 for 2025.
The two-thirds rule is the majority rule, not a universal one. Alaska, Iowa, Maine, and Michigan pay 80 percent of spendable or after-tax earnings, Connecticut uses 75 percent of net wages, Massachusetts and New Hampshire use 60 percent of gross, and New Jersey and Oklahoma use 70 percent. Michigan’s version runs off the highest 39 of the 52 weeks before the injury and caps benefits at 90 percent of the state average weekly wage. If you assume two-thirds of gross in one of those states, your estimate will be off.
Permanent disability works differently. Once you reach maximum medical improvement, a physician assigns an impairment rating, and the state converts that percentage into a set number of weeks of benefits using a statutory schedule. A rating on a scheduled body part, such as a hand, usually pays a fixed number of weeks regardless of whether you returned to work.
One more mechanical point: comp benefits are generally exempt from ordinary creditor garnishment in most states, though child support and certain government debts are treated differently from the rules that govern how wage garnishment works on regular paychecks.
What happens if the claim gets denied
Denials cluster around a handful of reasons: late reporting to the employer, no medical evidence connecting the diagnosis to the incident, a pre-existing condition the insurer argues is the real cause, or a dispute about whether you were in the course of employment when it happened. Commute injuries and injuries during breaks generate a disproportionate share of these.
The denial notice itself is the important document. It has to state a reason and tell you the deadline and forum for disputing it, and those two items determine everything that follows. Deadlines are short and strictly enforced, so the date on the letter matters as much as the reasoning.
From there the dispute moves into an administrative system rather than a regular court. The usual sequence is an informal conference or mediation, then a hearing before an administrative law judge, then review by a state commission or board. Wisconsin is a clean illustration: the Department of Workforce Development explains that any party may petition the Labor and Industry Review Commission within 21 days to reverse, modify, or set aside an ALJ’s decision, with circuit court review after that.
Evidence that tends to matter on appeal is the kind created at the time, not afterward: the original incident report, the first medical visit note, texts or emails telling a supervisor about the injury, and names of anyone who saw it. Keep copies of every letter from the adjuster, including envelopes, because mailing dates sometimes start the clock. The structure resembles how Social Security disability claims get decided, where contemporaneous medical documentation outweighs later statements about how bad things were.
Many denied claims resolve before a hearing, either because the worker produces a clearer medical opinion on causation or because the parties settle. A denial is a litigation position, not a final determination.
Frequently asked questions
Can you choose your own doctor? It depends on the state, and this is one of the biggest variations in the system. Some states let the employer or insurer direct care, sometimes through a posted panel of providers you must choose from for an initial period. Others let you pick your own treating physician from the start, or let you switch after a set number of days. Treating outside the rules can leave bills unpaid even on an accepted claim.
Does comp cover partial wage loss on light duty? Generally yes, through temporary partial disability benefits. The typical formula pays a percentage, often two-thirds, of the difference between your pre-injury average weekly wage and what you are actually earning on restricted duty, up to the same state maximum.
What if your employer says the injury did not happen at work? The claim goes to the same dispute process as any other denial. The employer’s opinion is evidence, not a decision. What usually settles it is the medical record, the timing of your report, and witness accounts.
Can you be fired while on workers’ comp? Being on a claim does not by itself protect your job, and in at-will employment states a company can generally terminate for unrelated reasons. Retaliating against someone for filing a claim is separately prohibited in every state, and some impose steep penalties for it. Job protection, medical leave rights, and disability accommodation are three different bodies of law that may apply at once, so an employment attorney in your state is the right place to sort out which ones cover you.
A practical next step while you wait: write down your adjuster’s name, claim number, and the date your claim was reported, then look up your own state’s accept-or-deny deadline and count forward from that date. Everything else in the process hangs off that one number.