There are many reasons why a workers’ compensation claim may be denied. Keep in mind that employers and/or insurance companies are often reluctant to admit an employee’s claim, as it means they will lose money. Here are some of the reasons a claim is often denied:
- Deadline Has Passed
In many cases, workers’ compensation is denied because the applicant did not report the injury or file the claim in time. If you do not report an injury to your work supervisor within a few days, you may be unable to claim workers’ compensation. There is also a deadline for filing a workers’ compensation claim: usually between 30 and 90 days from the date of the injury.
- Claim Disputed by Employer
Your employer can dispute a workers’ compensation claim by claiming the accident did not happen at work, or by claiming the accident occurred because of horseplay. The employer may also claim that the injury or illness is not work-related; in this case, more evidence is needed to counter the employer’s claims.
- Injury Not Eligible for Compensation, or is Not Severe Enough
In some states, stress-related injuries are not eligible for workers’ compensation. There may be other circumstances which preclude you from receiving compensation for a certain type of injury or illness.
Not all injuries are severe enough to warrant workers’ compensation. If your injury is judged to be only minor, your claim may be denied.
- Injury Not Work-Related, or Did Not Occur at Work
Workers’ compensation only applies to injuries and illnesses that are causally linked to the employer’s work. If you cannot show that your injury was caused by your job, you are not eligible for compensation.
Your claim may also be denied if your injury did not happen on your employer’s premises (or while you were on the job). If you sustain an injury while commuting to work, or while on your lunch break, for example, you cannot claim the injury occurred on the job.
However, there are some exceptions. If you were on a work assignment, such as a business trip or company retreat, you may still be eligible for compensation even if the accident did not occur “at work.”
- No medical treatment, or Not Treated by Approved Medical Provider
Most of the time, you must undergo medical treatment before you can receive compensation. If you don’t have a record of your visit to the doctor, your employer may claim that you faked the injury, since there is no evidence to show you sought treatment for it. Additionally, if you don’t allow a doctor to examine your injury, your claim may be denied.
Your employer may give you an approved list of doctors from which you can receive medical treatment for your injury. While this can sometimes be detrimental to your case if the doctor tries to downplay the injury, your claim may be denied if you do not receive treatment from an approved provider.
- Injury Occurred While Intoxicated or While Engaging in Horseplay
If you get injured while under the influence of alcohol or drugs, you are not eligible for workers’ compensation. Similarly, if you sustain an injury in a fight that you started, or if you get injured while violating company policy or “horsing around,” you are also not eligible. In some cases, your employer may claim that you were engaging in horseplay even if you were not.
What to Do If Your Claim is Denied
If your claim is denied, you should receive a letter informing you of the denial and telling you how to appeal it. Pay close attention to any deadlines, since missing these may prevent you from appealing the claim.
If the letter does not give a reason, you may have to contact your employer or your employer’s insurance provider to find out why the claim was denied. If your claim was denied because of a simple mistake in paperwork, or a similar problem, you should be able to work with your employer to fix the mistake. In other cases, you will have to appeal the denial of your claim.
Appealing a Denied Claim
To start the appeals process, you must file an application (either yourself or with the help of an attorney). You will then have to attend a hearing, usually through the state labor department or board of workers’ compensation, before a judge of administrative law. At your hearing, you must provide factual evidence for your claim, usually in the form of medical records – so make sure to bring plenty of documentation with you.
Just because your claim is denied does not mean you should give up. You may still be able to receive workers’ compensation for your injuries.