Filing for workers’ compensation benefits is not fun, but it is at least rewarding. That is, it should be a rewarding experience if the responding insurance company takes your claim seriously and agrees to give you financial payments to cover medical costs and possibly even some of your average weekly wages. If your workers’ compensation claim is denied, though, then you will have a bit of a legal process ahead of you.
To begin, you need to know why your workers’ compensation claim was denied in the first place. You should be given a letter of denial from the insurer that explains why they chose to deny your claim. However, the letter could be full of legalese that makes interpreting it difficult. Or you might not be sent a letter at all. In either situation, you will be wondering why your claim was denied.
Here are some of the most common reasons why insurance companies deny workers’ comp claims to hopefully shed some light on your situation:
- Expired statute of limitations: Perhaps one of the most common reasons on this list is also one that should be easily avoided: not taking action in time. After a workplace accident, you need to notify your employer as soon as possible, and they need to notify their insurer just as quickly. Depending on your home state, there will be varying statutes of limitations on how much time you have to tell your employer and/or file a workers’ compensation claim. When such a statute expires, the ability to file a claim disappears. The lesson here is to be proactive with your claim.
- Incorrect medical provider: The medical treatment you receive for your workplace injury must be carried out by an approved provider. Most states allow insurance companies to create a list of local healthcare providers for workers’ comp claims. When a worker is hurt on-the-job, they will be sent to the nearest approved provided for treatment, even if that worker has never seen that medical team before. Seeing a medical provider not on an approved list, assuming one exists, can undo the validity of your claim.
- No medical treatment: Just as seeing the wrong medical provider can mess up your claim, so can not seeing one at all. For any workplace injury, you should insist on seeing a medical provider for a checkup, even if you think your injuries are mild. If your injury becomes worse later on and you never saw a doctor, the responding insurance company will likely blame you for your injuries and toss out your claim.
- Impairment: If there is any indication that you were impaired due to drugs or alcohol when you were hurt on-the-job, then your case is certain to be denied. Intoxication and drug impairment are seen as intentional negligent acts, which invalidate workers’ comp claims, just as intentionally rocking a ladder back and forth until you fall over would be seen.
- Not at work: Workers’ compensation claims become quickly complicated when you get hurt outside of the workplace. Typically, not being at work means you are not eligible for workers’ compensation coverage, but not always. If you were outside of the workplace for a work duty, like getting hit in a car accident while going to pick up more ink for the office printer, then your claim could still be valid and the denial might be unjust.
- Preexisting medical condition: This reason is probably the absolute favorite among tricky insurance companies. If there is anything in your medical record that remotely resembles the injuries and symptoms you experience as a result of your workplace accident, then they will jump at the chance to blame that preexisting medical condition.
- Employer dispute: This last entry on the list is a denial caused by an employer, not technically an insurance company. Any time an employer has to tell their insurance provider that an employee was hurt so they need workers’ compensation benefits, they run the risk of seeing a monthly insurance premium hike. With this in mind, most employers will try to do their own investigation to determine the validity of a claim. Even when the law requires an employer to notify their insurer of an employee’s accident, some dishonest employers may outright dispute the claim and refuse to cooperate.
What Should You Do After a Workers’ Comp Claim Denial?
You can try to appeal your workers’ compensation claim denial on your own, but it is not recommended. Insurance companies are always prepared to counter arguments made by people without legal expertise. They keep defense attorneys on-staff in many cases to do just that.
To meet them at their level and challenge the denial with effectiveness, call a workers’ compensation lawyer. You will take the stress of the situation off your shoulders and gain confidence that your appeal will be handled on time and efficiently.