What are common reasons for workers' compensation denial?

Workers' compensation is meant to protect workers injured or falling ill while working by covering medical bills and lost wages. However, not all claims are automatically accepted. In fact, most of them are initially denied for any number of reasons. Being aware of the most common reasons for denial of workers' compensation will help you avoid pitfalls and make your case better should you be forced to file or appeal a claim.
1. Failure to Report the Injury Promptly
One of the most common causes of denial is not reporting the injury to your employer within the specified time period. Each state has a specified time limit by which an injury should be reported in the workplace—typically several days to a few weeks. Not reporting the injury in a timely manner could raise suspicion regarding the genuineness of the claim and create a reason for the insurers to reject the claim.
2. Disputes About Whether the Injury Was Work-Related
If your employer or their insurer feels that your injury didn't happen in the scope of your job or was not related to your job, your claim might be rejected. For instance, if you were hurt during lunch offsite or on your way to work, the insurer can contest that it wasn't specifically related to your job responsibilities.
3. Lack of Medical Evidence
Accurate medical documentation is paramount to getting a successful workers' comp case. Without proper diagnosis, medical reports, or linkage of the injury to work, the claim is most likely to be denied. Insurance firms also challenge claims in which a sanctioned or authorized physician has not treated the patient.
4. Pre-Existing Conditions
Insurers can also reject a claim if they determine that the injury is related to a pre-existing condition and not a new work injury. While pre-existing conditions do not automatically rule you out, you will need to provide medical evidence that the employment aggravated or enhanced the condition.
5. Missed Deadlines
Besides deadlines for reporting, there are also strict deadlines for filing paperwork, submitting medical reports, or appealing after a denial. Failure to meet these deadlines can have your case dismissed, even if it is legitimate.
6. Inconsistencies in Your Statement
If your explanation of how the injury occurred changes from one time to another or does not match up with medical records or with witness accounts, insurers may be suspicious. Your account should be consistent.
7. Injury Not Considered Serious
Minor injuries that do not warrant medical attention or time off from work might not be eligible for workers' compensation benefits. When an insurer perceives the injury as minor or feels it didn't affect your capacity to work, they can deny the claim.
8. You Were Under the Influence or Violated Company Policy
If you were intoxicated at the time the injury occurred or were violating company policy (e.g., horseplay or equipment abuse), your claim can be denied. Most workers' comp policies will not cover injuries resulting from intoxication, drugs, or misconduct.
Final Thoughts
Denial is not the end of your claim. Denials in the majority of instances can be appealed with additional evidence or clarification. If your claim for workers' compensation is denied, you may wish to discuss your case with a qualified attorney to review it, correct any issues, and pursue the benefits you are still entitled to.

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