Reasons Why a Workers’ Compensation Claim Is Denied

When an employee is injured at work, they can file for workers’ compensation benefits for medical expenses and partial replacement wages while the worker recovers. Many workers’ compensation claims are approved, however, there are also a large number of claims that are denied. It is important to remember that the more serious the injury, the more complex the claim, which puts the claim at risk of being denied or an insufficient benefit amount. This is why many injured employees turn to a seasoned work injury attorney for assistance.

The following are the most common reasons why claims are denied.

The employee failed to report the injury within the required time.

Each state has its own rules and regulations regarding the workers’ compensation process, including how long an employee has to report the injury to his or her employer. If the employee fails to notify their employer within the required time, the claim could be denied. This is why an injured employee should report the incident immediately.

The injury occurred somewhere other than at work.

A claim could be denied if the incident that caused the injury did not occur at the workplace. There are exceptions to that rule, however. If the employee was away from the worksite but was performing duties related to their job when they were injured, then they would qualify for benefits. Another example would be the employee traveling for their job and injured would also qualify for benefits.

The employee had a pre-existing condition.

If the employee had a pre-existing condition, the insurance company may be denied. Some medical conditions which could cause a denial include arthritis, congestive heart failure, diabetes, or epilepsy. In some cases, if the injury aggravated the prior condition, the employee would likely qualify for benefits.

There were no witnesses to the event that caused the injury.

When there were no witnesses to the accident that injured the employee, the insurance company may try to deny the claim by alleging the employee has filed a fraudulent claim. A skilled workers’ compensation attorney has successfully represented many clients who were injured in accidents without supervisors or other employees present.

The employee was under the influence of alcohol and/or drugs or was otherwise engaged in unsafe behavior.

If the employee was under the influence or other dangerous and forbidden behaviors, their claim will be denied. When an employee puts themselves in a position where they can get themselves injured, the employer and the insurance company are not liable for the injury and no benefits will be paid.

What can an employee do if their claim is denied?

Unless the employee was engaged in dangerous behavior or under the influence, there are steps an injured worker can take if their claim is denied. This is where having a job injury attorney can make all the difference. Having an attorney advocating for you minimizes the chances your claim will be denied, to begin with. But if it is, your attorney can file an appeal with your state’s workers’ compensation board who has the power to reverse the insurance company’s decision. In the event you need legal guidance, do not hesitate to reach out to a  professional, like a skilled Nassau County workers compensation attorney, or locals, to assist you with your case.

Thank you to Polsky, Shouldice, & Rosen P.C for providing their insight and authoring this piece on workers compensation.