The 4 Most Common Reasons Workers’ Comp Claims Are Denied & How to Avoid Them

If you were injured on the job and you’re now facing medical bills or time away from work, your financial situation may feel stressful and worrisome. Workers’ compensation benefits are designed to help you get back on your feet in this situation. 

While premiums for workers’ compensation policies aren’t taken directly from your paycheck, you still pay for these benefits and may be entitled to compensation. According to the Congressional Research Service, “although workers do not directly pay for workers’ compensation benefits, they may pay implicitly for their benefits through lower wages as employers shift some of their costs to their workers.”

Review the information below to learn more about common workers’ compensation denial reasons. Find out how to avoid these reasons so you receive the workers’ compensation benefits you deserve. 

1. There Is No Medical Evidence of Injury From an Approved Doctor

To qualify for workers’ compensation, an injury must have occurred at work. To verify the injury, an employer-approved doctor must analyze it and agree with you about what happened. As an injured employee, you’re required to seek analysis and treatment through an employee-approved doctor to receive workers’ compensation.

Unfortunately, a common misconception that workers’ compensation fraud runs rampant has led to this necessary proof of injury. However, this conception isn’t true and only 1% to 2% of workers’ compensation claims filed are actually fraudulent

What Not to Say to a Workers’ Comp Doctor

An employer-approved doctor will pay close attention to what you say before making their report. If you say anything about the incident that may cause a denial of your workers’ compensation benefits, the doctor may include these comments in his report. What you say may also influence the doctor to potentially claim your injury didn’t occur in the workplace at all. 

Tell the truth about the events that occurred but try not to exaggerate the injury or how it happened. For example, if a 10-pound bucket of paint fell on your arm, don’t say the bucket was actually 50 pounds. 

Remain polite when interacting with the doctor, no matter the questions you’re asked. Also, be mindful of speaking negatively about your employer since everything you say will be well-documented. For example, don’t blame the paint bucket falling on your supervisor who was at a different job site. It may be a red flag for the doctor, who may document information that could negatively affect your claim.

2. The Injury is Related to a Pre-existing Condition

The injury that an employer-approved doctor documents must be related to workplace conditions. Your claim may be denied if the doctor instead documents that your injury is related to a pre-existing condition

For example, if you have a pre-existing cardiovascular condition and experience an episode at work, your claim may be denied. Since your cardiovascular condition was pre-existing, workplace conditions may not be to blame for your episode.

How to Handle Aggravation of a Pre-existing Condition

If you feel your case isn’t related to a pre-existing condition, you must show evidence to prove this. Ruling out your pre-existing condition and isolating the workplace injury may allow you to qualify for benefits. If you were misdiagnosed for a condition and are currently pursuing a medical malpractice lawsuit, this may prove your condition doesn’t exist and therefore has nothing to do with your claim.

While a pre-existing condition may disqualify you from workers’ compensation, the aggravation of your current health condition in the workplace may make you eligible for benefits. However, it may be complicated to prove your workplace is what caused you to experience an injury. You may need to seek legal representation for your workers’ compensation claim to help prove your case.

3. Employee Intoxication or Horseplay Is to Blame

During investigation proceedings, a drug test may be administered to rule out the possibility that you were under the influence of alcohol or drugs. If your drug test comes back positive, you’ll likely receive a denial. Working under the influence shows that you’re not following company policies, which is a common reason for denial.

Additionally, if the investigation reveals that you weren’t following company policy in another way, such as engaging in horseplay or not wearing the proper safety gear that’s provided, your claim may also be denied.

Before you deny that you weren’t following company policy, consider the evidence your employer may have against you. Customers, co-workers, or supervisors may have been observing your behavior as the incident occurred. If your employment agreement or safety rules cover horseplay, intoxication/drug use, or other forms of potentially negligent behavior, these are likely to be used as cause for denial.

Your employer may also have cameras set up in common areas and this footage may show you acting inappropriately or not following company procedures. If you have a history of being reprimanded for this behavior, your employee record may also be used against you to potentially deny your claim.

Does Workers’ Compensation Cover Employee Negligence?

Some states follow a “no-fault” system when it comes to workers’ compensation claims, which means no matter who’s to blame for the incident, you’ll receive coverage. If you perform a dangerous job, you take on an assumption of risk, but your injury is still covered under workers’ compensation in a no-fault state. However, in some states, if you showed contributory negligence in the situation, your claim may be denied.

Whether a state implements a no-fault or at-fault system depends on its own workers’ compensation laws. Ohio, Wyoming, Washington, and North Dakota require employers to self-insure or obtain workers’ compensation insurance from the state fund. All other states allow employers to purchase workers’ compensation insurance through private companies.  

4. It Wasn’t Reported in a Timely Fashion

If you’re injured on the job, you have a deadline to file your workers’ comp claim. Each state has different laws, including the deadline for reporting a workplace injury. 

For example, in Colorado, a workers’ compensation claim must be reported within 10 days of the injury. However, in California, you have up to 30 days to file your workers’ compensation claim

When Should You Report a Workplace Injury?

It’s important to take note of the workers’ compensation reporting deadline in your state to be sure you’re still eligible to file a claim. You should always report your workplace injury as soon as possible. The longer you wait to report your injury, the more suspicious your employer and employer-approved doctor may be about whether your injury should be covered.

If you have a minor injury you feel may get worse, report it to your employer, even if you’re not sure you’ll need medical treatment. By reporting the claim, if you do decide to seek treatment, it’s more likely you’ll be covered.

As soon as an incident occurs, begin gathering witness testimony and taking note of the date and time it happened. If you do decide to file a claim, this information is helpful in building your case.

What Happens if Your Workers’ Comp Claim Is Denied?

If your workers’ compensation claim is denied, you may need to seek legal action. There are many reasons for a workers’ compensation denial but in some cases, it may be a misunderstanding. With legal representation on your side, you’ll have assistance throughout the appeals process. With a legal professional representing you, you can get experience help to obtain compensation you can use for medical bills and lost wages.

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