If you or someone you love has suffered from an injury at work, you may be entitled to compensation. Unfortunately, some insurance companies deny workers' comp claims because they don't want to pay out large amounts of money. This article explores the top reasons why your workers' comp claim can be denied.
Why would my workers comp claim be denied?
Workers Compensation can cover a wide range of injuries and illnesses that occur on the job. However, not all cases are approved by insurance companies. There are many different reasons why your claim could be rejected. Some common reasons include:
1. The injury was not job related.
This includes injuries suffered while playing sports, participating in hobbies, or engaging in other activities unrelated to employment. Some states have special rules about whether an injury occurred on the job if the worker was using tools or equipment provided by his employer. For example, if a worker slips and falls on ice outside of work, he might not qualify for workers' comp benefits even though his fall was caused by the slippery conditions on the company's premises.
2. The injury did not happen during working hours.
In many cases, this means that the accident happened when the employee was off-duty, such as after work hours or on weekends. However, there are exceptions. For instance, if a worker is injured while traveling to or from work, or if he suffers an injury while performing duties required by law, these events will usually be considered part of the course of employment.
3. The injury does not meet the requirements of the state's workers' compensation laws.
For example, the injury must be serious enough to prevent the worker from returning to his former position. It also has to be shown that the injury resulted in medical bills exceeding a stated amount. In some cases, you may also not be covered by state law. In some states, certain types of injuries are excluded from coverage.
4. The worker received adequate treatment before filing a claim.
Many people assume that if they receive medical care, they automatically qualify for benefits. But this isn't always true. A worker might receive medical attention but fail to follow up with the doctor's recommendations. Or he might seek help from a specialist only to find out that the condition doesn't require treatment beyond what he already receives at the primary care facility.
5. The worker failed to report the injury within a reasonable amount of time.
According to federal regulations, any injury that occurs at work should be reported immediately. If not, there will be what is called "failure to give notice." Failure to give notice means that you did not tell your supervisor about your injury within 30 days of its occurrence. If you wait more than 30 days to file a claim, you can still recover benefits, but you'll need to prove that the delay was justified under the circumstances.
6. The worker had a pre-existing condition
If you have an injury that happened before you began working with this employer, and your injury has nothing to do with an injury by accident in the workplace.
7. You filed a fraudulent claim.
Filing a false workers' comp claim can result in criminal penalties and civil lawsuits against you. Make sure that all information given to your attorney is accurate and complete. Also, make sure that you don't give her any misleading information. This includes things like dates, times, and places.
8. You haven't worked long enough to qualify for benefits.
This is one of the most common reasons why claims are denied. Most states set minimum periods of time that employees must work before being eligible to receive benefits. Usually, this period ranges from six months to two years but again, it depends on what is set by the state. Be mindful of how much time you have been working when you apply for benefits.
9. You're a seasonal worker.
Seasonal workers are sometimes not eligible for benefits.
Nonetheless, this does not mean that you cannot get benefits. Many states allow seasonal workers to receive benefits even though their employment is limited to a particular season. If you're a seasonal worker, check with your local office to see whether you qualify for benefits.
10. Your employer refuses to acknowledge liability.
When an employee files a workers' comp claim, the employer may deny responsibility for the accident. The denial may come in a variety of forms: denying that the incident ever happened, claiming that no negligence occurred, or arguing that the injury wasn't caused by the job.
Whatever form it takes, the employer may try to avoid having to pay benefits by making these arguments. This is because they know that if they admit fault, they'll have to compensate the injured party. However, this doesn't always work. In some cases, the court might find that the employer had knowledge of the risk involved and therefore is responsible for the injuries.
You can also fight back by proving that the employer's actions were negligent. Negligence involves doing something wrong that causes harm to another person. In other words, it's the opposite of "doing nothing wrong."
What should I do when my workers comp claim is denied?
When your workers comp claim is denied, there are some steps you could take. These include:
1. Contact the insurance company.
Contacting the insurance company is very important if your claim ends up being denied. You may have a lot of questions that the insurance company may be able to assist with. You can ask them about your rights as well as how to appeal the decision. You can also ask whether the denial was based on lack of coverage or lack of proof. If the answer is the latter, ask what additional evidence would be necessary to support your claim.
2. Review your records carefully.
Sometimes mistakes get made that you do not notice. Mistakes can be made through human error or poor record keeping. This is especially true when medical records are transferred from one facility to another. It's possible that you did everything right but the insurance company didn't realize that you qualified for benefits. Make sure that all of your paperwork is complete and accurate.
To do this, make copies of any documents that you think will be helpful. Then keep those copies safe so you don't lose them. You should also make copies of any notes that you took during your treatment. You should be as careful and critical as possible when it comes to your paperwork.
3. Seek legal advice.
It's possible that you have grounds for appealing the decision. However, you may not always know what grounds those are or how you can defend them. In this case, you may want to consider hiring an experienced workers' comp lawyer who knows how to appeal denials. A good attorney can help you prepare the best case possible. He or she can explain clearly why your claim has been denied and he or she can also advise you on how to proceed after the appeal is filed.
4. Hire an attorney.
If your claim has been rejected because of insufficient evidence, you could hire an experienced workers' compensation attorney. An experienced workers' comp attorney can help you evaluate your chances of success. That attorney could first and foremost help you decide whether you need to file a lawsuit. He or she will also be your guide on every step of the process.
What if I'm injured at work but I'm not covered under workers' comp?
If you're injured while working, you might be able to collect damages from your employer through a third-party claim. Third-party claims are separate from workers' comp claims. Instead of getting paid directly by your employer, you'd pay your own attorneys to pursue your claim against whoever is responsible for your injuries.
Do I really need a workers comp lawyer?
You should certainly consider it if your claim has been denied. A good workers' comp lawyer will make sure that your case gets fully investigated and that all relevant information is presented.
How can a lawyer help you when your workers comp claim is denied?
1. Helping you understand why your workers comp claim can be denied.
When you receive the letter that your claim has been denied, one of the first things you might feel is confusion . The letter doesn't tell you exactly why your claim was denied. And it doesn't give you details about how to appeal.
Your lawyer can help you understand the denial letter and answer some questions like these:
• What does the letter mean?
• How long does it take to hear back?
• Is there anything else I need to do?
2. Appealing the denial.
You may be entitled to appeal the denial. If you believe that you were wrongfully denied benefits, you should talk to your workers' comp lawyer about appealing the denial. Your lawyer can help you determine whether you have grounds for appealing and how to go about doing so.
3. Preparing your case.
An experienced workers' comp lawyer can help ensure that your case is prepared properly. For example, your lawyer can help you gather any medical records that support your claim and present them to the judge. He or she can also help you prepare your testimony.
4. Taking care of your legal issues.
Once you've appealed your claim, you'll likely have to wait for the outcome before you start receiving payments again. If you want to know what happens next, you should contact your lawyer. He or she can explain everything to you and keep you up to date on the status of your case.
5. Getting money for your injury.
After you've received payment for your injury, you may be eligible for additional compensation. This includes disability payments and vocational rehabilitation services. You should speak to your lawyer if you think you qualify for more than what you've already been awarded.
Oxner + Permar is here to help!
The workers' compensation system was designed to protect injured employees from losing their livelihood because of an injury. Unfortunately, many people don’t understand the process and end up having their claims denied.
This is where we come in. We have seen thousands of claims denied over the years and know exactly what to look for. We can help you avoid these common mistakes.
Contact us now to find out more.