Reasons Your Workers’ Comp Claim May Be Denied

Getting sick or injured while at work can be a stressful experience. If it happens, the first step is to file a workers' compensation claim to receive benefits. However, not all claims will be accepted. Over four million workers' compensation claims are filed annually in the United States. Some of these claims will be denied for various reasons. Denials of workers' compensation claims can be upsetting and confusing, leaving injured workers unsure of their alternatives and legal rights. In this article, we will explore some of the many factors for the denial of a workers' compensation claim. By highlighting these aspects, we hope to equip you with the knowledge to help you navigate the process more effectively and increase the likelihood that your claim will be approved. 

Reasons Your Workers’ Comp Claim May Be Denied

Remember that each workers' compensation claim is unique, and the reasons for claim denials might change depending on several variables, including the state, company policies, and the circumstances of the individual accident. If your claim is rejected, you have the option of appealing the ruling and must be able to offer more proof or reasons in your favor. In this section, we will look at some of the reasons why your claim for workers’ compensation has been denied.

Failure to Report in a Timely Manner

Workers' compensation claims require you to report an accident or injury that occurred at work within a certain period of time. If you do not disclose what happened within the state's disclosed legal time frame, the insurance provider can contest your claim, claiming that there is no proof connecting your injuries to your place of work. You must notify your employer of the injury by your state's deadline in order to be eligible for workers' compensation benefits. The typical deadline for giving this notice is around 30 days, but it may only be a few days depending on where you live. It is best to report the injury as soon as you can, regardless of your state's reporting date. It is likely that the insurance provider will be more cautious if you wait to file your claim.

In many states, you will also have a deadline for submitting an official claim to your state's workers' compensation office. Even so, you might be eligible for one of the few exclusions even if you miss the deadline.

Lack of Witness Support

Having witnesses who can accurately and honestly attest to your allegation can be important in various circumstances in a workplace accident, and the lack of can be a reason for your claim being denied. The insurance provider may doubt the veracity of your claim and later reject it if there were no witnesses to your accident or if their testimony differs from your account of what happened.

If you were alone during the accident and there is absolutely no witness support, it does pose some problems in a claim. However, most businesses should have some security cameras. If there were no witnesses, security camera footage might have caught the accident on its footage, which can be just as helpful in your claim.

A Pre-Existing Condition Caused Your Injuries

The insurance company may determine that your current condition is not primarily the product of your workplace accident if you have a pre-existing medical condition comparable to or connected to the injury you claim was caused by the accident. They can argue that your current medical condition contributed to or caused your damage, which would result in a claim being rejected. This is a common reason for claims being denied, and some insurance companies can push for this to be the cause. 

Generally speaking, if the new injury aggravated your previous condition, you should still be qualified for benefits. However, the insurance provider may dispute your claim or attempt to reduce your benefits by arguing that your need for medical attention or compensation for permanent disability is primarily due to the pre-existing condition. If this happens, you may have to undergo an independent medical examination and other legal processes to resolve the dispute.

The Accident Happened as a Result of a Policy Violation

The insurance provider can argue that your carelessness contributed to the accident if a violation of safety procedures or organizational policies brought on your injury.. As a result, they can reject your claim because the damage was not caused by anything related to your job but rather by your own careless activities. This can include things like not wearing the proper safety gear on a job site, participating in horseplay, and getting hurt.

For example, let’s say your warehouse job requires you to wear a reflective safety vest to help vehicle drivers see you. One day, you are walking through the warehouse and forget that your vest was left in your locker. You’re running back to get it from the locker, and you get hit by a small vehicle and get injured. This claim for workers’ comp could theoretically get rejected because you were not wearing the proper safety gear.

If the Injuries or Illness is Not Work-Related

Your claim will probably be rejected if your employer or the insurance provider does not think your accident or illness was truly work-related. Generally, for workers’ compensation claims to be approved, the injury or illness has to happen when the employee is doing something for the employer’s benefit or your work was the direct cause of the injury or illness. 

Your claim might be approved if you are hurt on a business trip or working away from the office or job site. However, it’s important to remember that traveling during an everyday commute or when you were not actively working when the accident occurred is not covered by workers’ compensation claims. 

Involvement of Drugs & Alcohol

If you were under the influence of drugs or alcohol at the time of the workplace accident, it’s almost certain that your claim for workers’ comp will be denied by insurance companies. As almost every employer has some sort of policy on alcohol and drug abuse in the workplace, this is an automatic denial in most cases. 

What Happens to Medical Bills When Workers’ Comp Is Denied?

Medical bills will still remain even if your workers’ compensation claim is denied. You might ask yourself, “What happens to my bills if my claim is denied?” Don’t worry. There are still options for covering your medical expenses and even getting compensation from the employer or insurance company to cover medical costs. In this section, we’ll cover some of the ways your medical costs can be covered.

Personal Health Insurance Coverage

If your workers’ compensation claim is denied, your personal medical insurance could potentially cover some, if not all, expenses. Follow the standard procedures of your personal health insurance plan. This may mean that you have to cover deductibles, co-pay, or coinsurance costs required by your policy.

Legal Action

If your workers' compensation claim has been denied and you believe the decision was incorrect, you can choose to sue your employer or the insurance provider. You can navigate the legal system and pursue the reimbursement that you are entitled to by hiring an experienced workers' compensation attorney with expertise in workers' compensation law. To fully grasp the particular rules and laws where you live, it is essential to get proper legal advice.

Negotiate with Medical Providers

In some cases, you may be able to work out a payment plan or delay billing of medical costs with your medical providers until the workers' compensation claim is settled. If healthcare providers know you are actively pursuing your claim or if there is a chance of future compensation, they may be willing to cooperate.

What To Do if Your Claim is Denied

Your claim for workers’ compensation has been denied. Now what? There are ways for you to bounce back from a claim denial, as you still have rights as an employee. If you believe your claim was wrongfully denied, read more in this section about your next steps and how you can still get the compensation you deserve.

Carefully Review the Denial Letter

Read the insurance company's denial letter very carefully. It should list the particular justifications for the denial. You can properly plan your future steps if you know the reasons behind denial.

Gather All Relevant Documentation

Gather all the required documentation for your work-related illness or injury. This includes any supporting documentation for your claim, such as medical records, doctor's notes, diagnostic results, witness testimonies, incident reports, and more. Make sure your documentation is accurate, thorough, and well-structured.

Consult with a Workers’ Comp Attorney

Seeking legal advice from an experienced workers' compensation attorney is necessary at this point. An attorney can study your claim, evaluate the grounds for the rejection, and assist you with the appeals procedure or other applicable legal options. They can advocate for your interests, assist you in navigating complicated legal systems, and gather more evidence.

Appeal the Rejection

The majority of states have a procedure for appealing workers' compensation decisions. Follow the guidelines for filing an appeal, including the deadlines. Typically, you will need to fill out specific paperwork and submit it to the proper administrative board or workers' compensation board. During the appeals process, concentrate on making your case stronger. This may involve getting additional medical opinions, getting an expert to testify, or gathering further proof to refute the previous denial's justifications. You can get help from your lawyer in developing a strong case and effectively presenting it.

Before or during the appeals process, parties may occasionally hold mediation or settlement talks. To accomplish this, you will need to negotiate with your employer or the insurance provider to come to a mutually acceptable agreement. A simpler and time-consuming option to litigation is mediation.

Legal Resources for Injured Employees

It is essential to put your health and well-being first above all else if you, a loved one, or someone else you know has experienced a workplace accident. Even if you feel OK after the accident, make sure you get immediate medical assistance and are in good physical and mental health. If you need assistance with your workers' compensation process, you can discover helpful information in this section.

OSHA

The Occupational Safety and Health Administration (OSHA) was formed in 1970 to ensure that all workers have safe and healthy working environments. In order to achieve this, OSHA sets and enforces rules for all businesses and provides them with complete training opportunities, outreach, assistance, and information. OSHA provides resources and assistance to both employers and employees in the event of an accident. They provide information, instruction, and claim submissions for employees hurt due to a workplace accident, and their resources cover a wide range of topics relating to workplace accidents. To learn more about the services they can offer to injured employees, visit their website.

Workers’ Injury Law & Advocacy Group

The Workers' Injury Law & Advocacy Group, a nonprofit membership organization with offices around the country, was established with the intention of protecting the rights of the millions of employees and their families who suffer the consequences of workplace accidents and illnesses each year. The primary objectives of the organization are to assist attorneys and nonprofit groups in advocating for the rights of injured workers by gathering data, educating the public, and communicating. The organization was founded in 1995 by a small group of claimants' attorneys, and it now has more than 1,100 members from all 50 states. Paralegals, single practitioners, and attorneys from sizable law firms are among their members. Every day, the WILG works to make sure they can adjust to the new problems faced by injured workers. 

National Council for Occupational Safety and Health

The National Council for Occupational Safety and Health is committed to advocating for safe and healthy working conditions for all employees. At the end of each shift, National COSH works to ensure that all employees can go home safely and with the ability to earn a living. To achieve fair, just working conditions and create a strong movement encompassing racial, economic, and environmental justice, COSH groups bring together workers with labor, community, legal, and health alliances. Discover more about their services and resources here.