Common Reasons Workers’ Compensation Claims Are Denied
Common Reasons Workers’ Compensation Claims Are Denied
Why work injury claims are denied (and what to do if your claim is rejected)
Just because your workers’ compensation claim was denied at first doesn’t mean you won’t ultimately receive workers’ compensation benefits. Learn why insurance companies and employers commonly deny claims and what you can do about it.
Workers’ compensation is a form of insurance that pays medical expenses and lost wages to employees who are injured or become ill as a result of their job.
Though it would be nice if workers’ compensation benefits were paid without much of a fight, the process is often much more contentious.
Let’s look at the most common reasons why an employer or insurance company might deny your workers’ compensation claim and what steps you can take if they do.
Reason #1: Your employer isn’t required to carry workers’ compensation
Almost all employers are required to carry workers’ compensation insurance. There are, however, narrow exceptions that vary from state to state. Some of the more common exceptions found in some states include:
Individuals whose employment is both casual and not in the usual business of the employer
Businesses with fewer than 5 employees
If your employer isn’t required to carry workers’ compensation insurance, your claim will be denied. Keep in mind that if your employer is required to carry workers’ compensation insurance but doesn’t, the employer is subject to hefty penalties and you’re entitled to sue the employer for reimbursement.
Reason #2: Missed deadlines
All states have notice and filing requirements that must be met by injured employees. For example, in Arizona, an injured employee must notify their employer and then file a workers’ compensation claim within 1 year of the date of the injury.
If you fail to meet the applicable notice and filing requirements, your claim might be denied.
In general, it’s a good idea to file your claim as soon as possible. If you wait a long time (even if your claim is ultimately filed before the deadline), your employer or the insurance company may become suspicious as to whether you were actually injured at work.
Reason #3: Insufficient evidence that the injury is work related
Injuries are only covered by workers’ compensation insurance if they occurred “on the job.” Precisely what this term means varies from state to state.
In general, an injury occurs “on the job” if it happens:
Within the period of employment
At a place where the employee may reasonably be performing their duties
While the employee is fulfilling their duties or engaged in something connected with their duties
In addition, the injury must generally arise out of the employment. This simply means that there must be a connection between the work required to be performed and the resulting injury. This last point can be a little confusing, so let’s take a look at a couple of examples.
Bob is a software engineer. While sitting at his desk coding a program, he suffers a heart attack.
In this example, there’s no connection between the work being performed (coding) and the injury (heart attack). Consequently, Bob’s injury didn’t arise out of his employment and he can’t receive workers’ compensation benefits.
Laura is a bricklayer. While lifting a heavy stone for a wall her company is constructing, she hurts her lower back.
In this example, there’s a clear connection between the work being performed (lifting heavy stone) and the injury (lumbar muscle strain).
Reason #4: The injury isn’t covered
Most injuries are covered so long as the injury occurred on the job. However, there may be exceptions depending on where you live.
For example, in some states, heart conditions and mental illness aren’t covered. In other states, stress-related injuries aren’t covered.
It’s a common myth that employees can’t receive compensation for pre-existing injuries. In most cases, if you have a pre-existing injury that’s temporarily or permanently aggravated by a work-related accident, you’re still eligible to receive workers’ compensation benefits.
Reason #5: There are discrepancies between your accident reports and your medical records
When an employee is injured on the job, the employer generally conducts a small investigation and drafts an accident report. As part of this investigation, the employer might interview witnesses and review photographs and surveillance footage.
An insurance company will review the accident report and also conduct its own investigation. As part of this investigation, the insurance company will review your medical records. If there’s a significant discrepancy between the accident investigation and your medical records, your claim might be denied.
For example, let’s say you fall from a ladder at work and get hurt. However, because you’re embarrassed (or because you’re worried you’ll get in trouble with your employer), you tell your doctor that you injured yourself in a skiing accident.
In the above example, the insurance company will likely identify this discrepancy and deny your claim.
To avoid this sort of denial, be honest when talking to your employer and all medical professionals.
What should you do if your claim is denied?
Just because your claim is denied, doesn’t mean you won’t receive workers’ compensation benefits. All states provide claimants with an opportunity to appeal a denial.
Facing factsAccording to a recent study, 67% of workers’ compensation claims that are initially denied turn into paid claims. That means 2 out of every 3 denied claims are ultimately paid out!
In all cases, you must file your appeal within a certain amount of time (usually around 90 days from the date of the denial). The appeal process differs from state to state, but generally involves a hearing where you can present evidence.
What’s more, even if you lose your appeal (i.e., the decision to deny your claim is affirmed), you can, in most cases, have the appeal decision reviewed by the appropriate court of appeals.
If your workers’ compensation claim is denied, you should strongly consider hiring an attorney to represent you in your appeal.
How do you find the right attorney?
In addition to asking friends and families, there are a number of online directories that can help you locate an attorney. These include the state bar directory and the free online directory at Enjuris.
When you think you’ve found an attorney, be sure to ask them the following questions to make certain they’re the right attorney for you:
How long have you been practicing law as a licensed attorney?
What percentage of your practice is devoted to workers’ compensation cases?
How many workers’ compensation appeals have you handled?
Can you provide me with references and testimonials?