Why Workers’ Comp Claims Are Denied and How to Fight Back

Improve chances. Settlement negotiations.

Workplace injuries are more than just an inconvenience. If you need medical treatment, miss work, or suffer loss of income, they can be life-altering. If you’re hurt on the job and your employer denies your workers’ comp claims, your financial situation could become dire. But you can fight back. Here’s what to know about workers’ comp claims, common reasons for denial, and how to improve your chances for compensation.

What is Workers’ Compensation?

Workers’ compensation is a type of insurance policy held by employers. It’s used to provide medical care, benefits, and wage replacement when you suffer an on-the-job injury. When you file a workers’ comp claim, you agree to avoid litigation with your employer in exchange for the medical benefits and pay while you recover. In short, if you accept the workers’ compensation, you won’t sue them for negligence.

Why Are Claims Denied?

About 25% of workers’ compensation claims are subject to denial. The best way to improve your chance of claim approval is to avoid the mistakes that cause the most denials. The most common reasons for denial include:

  • The injury did not happen at work. It’s easy to prove when an injury occurred while on your employer’s property. However, it’s not as easy to verify when it occurs off property while performing job duties. Many employers’ insurance companies try to prove it wasn’t actually a workplace injury to avoid paying and supporting the claim. As a result, this reason for denial is more challenging to fight than others.

  • You fail to notify your employer within the required time. Workers’ compensation laws require you to report your injury within a specified time after the accident. When you fail to do so, it opens you up to suspicion about the injury, the timing, and the location. Reporting a workplace accident as soon as possible makes it easier for them to investigate. It also makes it harder for them to assume it was a pre-existing condition or something that happened elsewhere.

  • You received out-of-network medical care. If you received medical care from a provider that isn’t employer-approved for workers’ compensation cases, your claim could be denied. You must seek care from approved doctors or medical groups after a work-related injury.

  • The injury was your fault. Even though the workers’ compensation is a no-fault system, a claim could face denial for valid reasons regarding the fault. This can include injuries from messing around, being under the influence of drugs or alcohol at the time of the injury, or if the injury occurred while you were purposely injuring someone else in a physical altercation.

  • You have pre-existing conditions. If you have a leg injury from playing football in college years ago and you suffer a leg injury on the job, the insurance company may consider that previous injury a pre-existing condition. They might try to avoid coverage by blaming your injury claim on that previous injury.

  • You don’t seek medical care. Even if you report a work-related injury immediately, your employer could still deny your claim if you don’t seek medical care after the fact. Even if the injury seems minor, the only way to prove it is to have documentation by a medical professional, and generally one approved by your company to provide workers’ comp care.

How to Fight Workers’ Comp Claim Denial

There are ways to fight back when your employer denies your claim. All of them start with an experienced attorney. Whether you have a serious claim and want to ensure its approval or you’re dealing with a denial, an attorney is a critical component in ensuring a claim’s success and settlement negotiations should it get denied. A lawyer knowledgeable about the workers’ compensation system will help you navigate the process before, during, and after you file the claim. A paper cut on the job may not require legal support, but suffering a severe or catastrophic injury absolutely will. They can help you understand the reason for the denial and represent you as you fight the decision to get the benefits and pay you deserve.

When a quarter of all workers’ compensation claims face denial, it can be daunting to try to get appropriate coverage of lost wages, medical care, and benefits while you recuperate after an on-the-job injury or accident. But you can’t let the statistics discourage you from filing a claim for benefits you rightfully deserve. Denials are often strategic plays by your employer and their insurance company to avoid paying for coverage of the injury. Equipping yourself with the right tools and support is the best way to protect your rights as an employee and get the benefits you deserve. Contact the experienced, knowledgeable, and compassionate legal team at Carr Legal Group today to schedule your free workers’ compensation claim consultation.

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