Claims get denied all the time, even though it’s a no-fault system. Maybe you missed a deadline. Maybe your employer or the insurance company doesn’t think your injury is serious. Or maybe they don’t believe it happened at work. Whatever the reason, a denied claim means no medical coverage or lost wage benefits, leaving you stuck.
If you’re dealing with a workers’ compensation claim, the first step is understanding why it got denied. Some issues, like missing paperwork, can be fixed easily.
Others are more complicated and might require legal help. Either way, knowing the most common reasons for denial can help you avoid mistakes or figure out what to do next.
Let’s go over the five biggest reasons workers’ compensation claims get denied.
Failure to Report Injury on Time
If you don’t report your work injury on time, your workers’ compensation claim can be denied. Insurance companies have strict deadlines, and if you miss them, they might argue that your injury didn’t happen at work or isn’t serious enough to need benefits.
For example, if you slip and hurt your back but wait a week to report it, they could say you got injured somewhere else. Without an immediate report, there’s no solid proof that the accident happened on the job.
Most states require you to report workplace injuries within a few days. Even if the injury seems minor, report it immediately, document what happened, and make sure it’s in writing. This prevents delays and gives the insurance company less reason to deny your claim.
Inadequate Medical Evidence
If your medical records don’t clearly show that your injury is work-related, your workers’ compensation claim can be denied. Insurance companies rely on medical evidence to decide if they’ll approve your claim. If there’s not enough detail, they can argue that your injury didn’t happen at work or isn’t serious enough to need benefits.
For example, if you hurt your back lifting heavy boxes but don’t see a doctor right away, there’s no official proof that the injury happened at work. Even if you do see a doctor, if your records just mention “back pain” without explaining what caused it, the insurance company might deny your claim.
To avoid this, get medical attention immediately, tell your doctor exactly how you got hurt, and make sure your records are detailed. The more clear and complete your medical evidence is, the harder it is for the insurance company to deny your claim.
Injury Connected to a Pre-Existing Condition
If the insurance company believes your injury is due to a pre-existing condition rather than your job, they can deny your workers’ compensation claim. They might argue that your pain or health issue existed before and wasn’t caused by work, so they aren’t responsible for covering it.
For example, if you’ve had knee problems in the past and then injure your knee at work, the insurance company might say your job had nothing to do with it. However, workers’ comp can still cover injuries that make a pre-existing condition worse, but you need medical proof. A doctor must confirm that your work directly aggravated your condition.
To avoid denial, be honest about any past injuries, but make sure your doctor clearly states how your job made the condition worse. Without solid medical evidence, the insurance company can easily reject your claim.
If The Injury Isn’t Work-related
Workers’ compensation only covers injuries that happen because of your job. If the insurance company believes your injury happened outside of work or wasn’t caused by your job duties, they will deny your claim.
For example, if you report a back injury but there’s no clear work-related cause, the insurer might argue you got hurt somewhere else. If there were no witnesses, no immediate report, or conflicting details, they might question whether it really happened on the job. To avoid denial, report your injury immediately, provide a clear explanation of how it happened, and get medical documentation linking it to your work. Without solid proof, the insurance company can easily reject your claim.
