An employee’s injury occurred in the normal course of business, and he or she submitted a properly-filed workers’ compensation claim. It comes back denied. How can that be? Why would an otherwise perfectly valid claim be denied? Here are a few common reasons for a denial of a workers’ compensation claim. We have asked attorney Alaina Sullivan about what you should do. Here is what she had to say: Not Filing a Timely Claim One of the biggest reasons for a denial of a workers’ compensation claim has to do with timing. Each state has its own set of strict rules as to when claims need to be submitted following an injury. Many states require that the employee inform the employer of the injury within days of the incident, and then the employer also has a timeline for when he or she needs to submit the claim to the state. Failing to meet any of these deadlines can result in a complete denial of the worker’s claim. Employer Disputes Injuries Occurred at Work Another common reason for claim denial is the employer disputes that the injuries included in the claim happened at work. The employer may claim that the accident did not happen at work or was a result of a pre-existing medical condition of the employee. The employee will need to submit proof that the accident occurred on the job, and this proof includes evidence from the scene of the accident, as well as eyewitness testimony. A physician’s statement can also accompany this evidence to show how the injury occurred and to prove that the injury was not connected to any preexisting condition. Questions Regarding Employee’s Ability to Work To receive workers’ compensation benefits, the employee needs to be essentially unable to perform his or her job. This qualification is otherwise known as temporary total disability or permanent disability. If the employee is able to work, he or she will not be able to get workers’ compensation. The point of workers’ compensation is to “compensate” the employee because he or she is not able to work and earn an income because of an at-work injury. If an employer believes the employee is trying to scam the system and make his or her injuries seem more severe and serious than they really are, the claim may be denied. The employee can file an appeal and fight this denial if, in fact, he or she is not able to work and the injuries are serious enough to warrant the claim. Along those same lines, if the employer does not believe the injury requires time off of work, the employer may also deny the filed claim. The injury sustained at work must actually make it so that the employee cannot be at work and needs extended time for recovery and treatment. If the injury does not require recovery and treatment, the employee may find himself or herself in an uphill battle appealing a claim that is denied for this very reason. The Injury Does Not Require Treatment Lastly, if the injury the employee sustained did not require him or her to receive any kind of medical treatment, the employer and/or the insurance provider may deny the claim. Workers’ compensation insurance typically reimburses or covers the medical expenses associated with the injury and the resulting treatment and medical expenses. If the employee does not require medical treatment, the employer may wonder if the injury is really all that serious to justify workers’ compensation. It is possible the employee needs to be off work for an extended period of time because of the injury, but red flags are raised if the employee needs to be off of work and does not even need to see a physician for his or her injuries to at least be examined to ensure that no serious damage was sustained. The injured employee may find himself or herself fighting with the employer to receive benefits in these types of situations. Contact an Attorney Today If you have been hurt in an accident while on the job and were denied your workers’ compensation claim, it is always recommended that you contact an attorney to answer your questions. A licensed attorney trained in workers’ compensation law will be able to review your case and determine your best course of action. To receive the compensation you deserve, contact an attorney in your area today. Additional Resources My Claim was Denied. Can I Appeal It? Denied by Insurance
