The Top 5 Reasons Why Workers Compensation Claims Are Denied.
It's been noted elsewhere in these Articles, that the workers' compensation law is supposed to be self-executing. In other words, automatic. What we see in practice is that is simply not the case. Injured workers are denied benefits by insurance companies each and every day. The Workers’ Compensation Commission runs multiple courtrooms throughout the state that each and every year handle thousands upon thousands of claims contested or denied by an insurance company. A distinction here is important. One one hand, we see carriers denying a benefit- such as a medical service for a wage loss benefits within the context of a larger, accepted, workers’ compensation claim We also see an outright denial of the claim in its entirety, on the other. This Article deals primarily with the outright denial of a claim in total. However, that is not to say that the denial of a needed benefit- such as the provision of medical care, or the payment of lost wages, is not a vital, or potentially vexing concern. Here, a seasoned worker's compensation attorney can petition the court to ask a commissioner to order that the denied benefit be provided.
Claims are frequently denied where the employer either fails to report a case to a workers compensation carrier, or fails to fill out the appropriate paperwork such as a first report of accident or injury. If the accident is never reported, the insurance company is going to assume it never happened.
Another popular reason for denying a claim is based on the contention that there was no injury. These denials can be based on something as simple as a carrier, or an employer, stating that individual didn't get hurt, or there was no accident, or there was an accident- but the worker didn't get hurt.The denial of claims based on this line of argument can also be more nuanced.
I’ve seen carriers stating even though there was an injury, it was not as a result of workplace activity, but rather the result of a inherent flaw in the worker’s body, something known as the idiopathic condition.
I frequently see claims being denied where the workers' compensation insurance carrier contends that although there might have been an accident, and although there might have been an injury, the injured worker was not “ within the scope and course of their employment” while injured. A slight variation of this denial occurs where the carrier contends that although there was an accident, and an injury, and the person was in the scope and course of their employment, the injury did not arise out of the employment, or did not arise out of the activities associated with the employment. Workers compensation insurance companies frequently contend that although a worker might be injured due to a workplace accident, it turns out that
The injured worker really wasn't an employee after all, but rather was an independent contractor, and thus not covered by workers compensation insurance.
Claims are sometimes denied for a multitude of reasons that can be perhaps best generalized as “employee misconduct.” Here, the insurance company contends that although an accident happened, and an employee was injured, they should not be entitled to workers compensation benefits because of some misconduct. Here, you see arguments like:
“It was actually the employee's fault because they violated a safety rule”.
There have also be contentions that employee failed a drug test or was somehow under the influence of an illicit substance.
This is not to say that there are valid reasons for denying a workers compensation claim. Clearly, if someone fakes an accident or injury and pursues a fraudulent claim- that person is not entitled to workers compensation benefits and denial of such a claim would be appropriate. But, what we're talking about in this Guide are valid claims of an accident leading to an injury for an employee, who needs medical treatment and wages loss benefits, and yet the insurance company denies the claim for one of the five reasons discussed above, or other, yet more creative reasons.
I've handled hundreds of contested workers compensation cases throughout the years. If you have been hurt at work, or have questions about the benefits to which you might be entitled, or, have benefits due to you that are being wrongfully withheld, I would urge you to contact me today. I utilize an initial case analysis evaluation process and strategy conference for all injured workers, and I extend this process free of charge.
-This Article was updated by Eric Kirk on 7/31/20.