Why Are Work Injury Claims Denied?

When you’re injured in the workplace in the United States, you can report your incident for your employer to file a workers’ compensation claim. Once approved, you receive benefits to cover medical expenses, replace a percentage of your lost wages, and provide rehabilitation costs, such as chiropractic care and physical therapy. However, not everyone who files a workers’ compensation claim will have it approved. They can be denied for some of the following reasons: 

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Not Following or Seeking Treatment

In most situations, an injury or illness can be improved with a form of healthcare. For example, someone injured in a car accident in Atlanta may improve their outcome by visiting Atlanta car accident chiropractors.

However, if you were injured in the workplace, filed a claim, but didn’t seek treatment or follow your healthcare provider’s recommendation, your workplace’s insurance company may deny the claim.  

This is because many states require their employees to report their injury and get examined by an approved provider. Not receiving treatment may also mean there’s a lack of proof of injury. Insurers might even question the severity of an injury if the employee never sought medical care. 

Failing to File a Claim On Time

Some insurance companies choose to deny workers’ compensation claims because they weren’t reported in a timely manner. Employees must tell their employers promptly, or at least within days. Late reporting can make it harder to verify that an incident occurred.

Alongside needing to report an incident or accident to an employee promptly, you also need to file an official claim with your workplace’s insurance company within 1-2 years. However, the timeframe varies by state. If you’re filing an appeal after being declined, you must do so within 30-90 days, depending on the insurer.  

The Injury Being Work-Related Is Disputed

For a workers’ compensation claim to be approved, the injury or illness must have occurred due to a work task and during the course of employment. If it’s not, the insurer can deny the claim. Insurers often deny claims when the incident happened off-duty, while the employee was commuting, or when it was a pre-existing condition. 

The Condition Is Pre-Existing

While not true of all insurers, many workplace compensation insurance providers will deny an injury claim if medical records show that you already had the injury or condition. In this instance, the insurer may argue that the workplace incident didn’t cause your injury, or that it only aggravated a non-work injury. 

The Injury Isn’t Covered by Workers’ Compensation

Despite happening in the workplace, not all injuries are eligible for workers’ compensation. For example, if you were injured while intoxicated, injured while violating company policy, or your injuries were self-inflicted, these are all examples of when your workers’ compensation claim can be denied. 

There Is a Lack of Evidence 

An injury can occur at work and be considered a work-related injury, but that doesn’t mean there’s enough evidence to prove it happened, or to prove that it occurred in the manner you claim. A lack of evidence or any signs of inconsistencies can be enough for your workers’ comp claim to be denied. This is especially true if the accident reports and witness statements are conflicting, or if records are missing that undermine your credibility. Fortunately, if your claim is denied through a lack of evidence, it can be remedied by simply providing more evidence to support your claim. 

Your Employment Status Is an Issue

Your employment status is unlikely to be the reason a workers’ compensation claim was denied if you’re a seasonal, part-time, or full-time employee with your company. Even undocumented workers can receive workers’ compensation in many cases. 

However, if you’re an independent contractor, you’re not considered an employee, which means you’re not eligible for workers’ comp benefits. Sole proprietors are also typically excluded unless they include themselves in a policy.  

Small Errors and Missing Information

Claims aren’t always permanently declined. In fact, many claims submitted are only declined because there are minor errors or not enough information for the insurer to make an informed approval decision.

That’s why taking your time on your claim form can be so important. Read through it thoroughly and ensure you’ve attached all relevant documentation, such as medical reports and witness statements. 

You Didn’t Follow the Rules

Both employers and insurers can have rules that you need to follow in order to have your claim approved. If you don’t follow them, your claim can be denied. For example, if you must cooperate with an investigation and fail to do so, a claim denial can be the outcome. The same goes for if you need to attend a medical evaluation, and you don’t turn up. 

How to Improve Your Chances of Having Your Claim Approved

Having a workers’ compensation claim denied can be frustrating when you’re relying on the benefits to cover your everyday costs and medical care. However, there are actions you can take to improve your chances of claim approval: 

Reporting the Injury When It Happens

As soon as you’re injured or when you discover your injury, report it to your employer right away. Alongside oral reporting, provide details in writing, including the date and location of the injury, the circumstances surrounding it, and any witnesses who can provide statements. 

Seeking Medical Care Right Away

Even if your injuries are only minor, seek medical care right away. What’s more, ensure that the medical provider you use is one that is approved by your employer’s insurer, if that’s something they require. 

Follow all treatment recommendations since ignoring medical advice or missing appointments can significantly impact your claim. 

Document Everything

Workplace compensation insurers want to know everything there is to know about an event that led to an injury before they make a decision on your claim. Document everything related to what happened, so you can provide it when requested, including:

• Accident reports
• Medical records
• Prescriptions
• Employer/insurer correspondence
• Time-off slips 
• Witness written statements 

Follow Deadlines

There are strict filing deadlines for workers’ compensation claims, so it is essential to be aware of them and follow them accordingly. You are then less likely to be denied for filing too late. 

As frustrating as a work injury claim denial can be, it’s sometimes possible to reduce the risk of it happening. Awareness of the most common causes puts you in a strong position to make the right decisions for your own unique claim.

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