Workers’ compensation is designed to financially support employees who have been injured on the job, but getting a claim approved can be challenging. It’s surprisingly common for workers’ comp claims to be denied, even when the claim is perfectly valid. This is caused by a variety of factors, including automated processes, incomplete paperwork, and mistakes. However, some valid claims are denied maliciously, either by the insurance company or the employer.
Sometimes you need a lawyer in order to get compensated for a work-related accident. For example, if an employer doesn’t carry workers’ comp insurance when they should have, an injured employee might have grounds for a lawsuit. In other situations, employees hire lawyers to win appeals and get claims approved when their employers are interfering with their case.
Outside of these circumstances, injured employees don’t typically have the option to sue their employer, and are required to file a workers’ comp claim to recover financial compensation. For this reason, understanding the potential obstacles to getting a claim approved is crucial for employees seeking compensation through this program.
Why are workers’ comp claims denied?
Denials happen for many reasons, but the underlying cause is that insurance companies are trying to protect their profits by denying claims as often as possible. This is why a tiny mistake can ruin someone’s ability to get their claim approved.
- Failure to report the injury promptly. Employees are required to report an injury to their supervisor within a reasonable timeframe (this varies by state but is anywhere from a few days to a month). Failing to report an injury can result in a denied claim. Employers need time to conduct an investigation and file the proper paperwork. When reporting is postponed, it creates suspicion regarding the connection to work-related activities.
- Insufficient medical documentation. A workers’ comp claim can only be substantiated by medical documentation. Without details of the injury, the insurance company is likely to deny the claim.
- Medical discrepancies. If the employee’s account of the injury doesn’t match medical records, that’s a red flag for the insurance company.
- Pre-existing conditions. Sometimes it can be hard to distinguish old injuries from new ones. If the injury cited in the claim overlaps a pre-existing injury, it can be hard to prove without expert testimony or detailed medical evaluations.
- The injured party engaged in prohibited activities. Workers’ comp insurance policies explicitly exclude coverage for injuries caused by horseplay, pranks, intoxication, or similar behaviors.
- Missed deadlines. Not filing a claim or required documentation by the deadline can result in automatic denial.
- Incomplete paperwork. If a claim contains errors, it might be denied.
These are just the main reasons claims get denied. There are plenty of nuances within each of these categories that can lead to denial. It’s unfortunate that valid claims get denied for technical errors, so if you’re going to pursue workers’ comp, it’s crucial to ensure all of your paperwork is correct before submitting your claim.
Sometimes employers block access to compensation
In some situations, claims are denied when employers interfere and attempt to block the injured employee from getting approved. They might deny responsibility for the injury by saying it didn’t happen at work, dispute the details of the injury, threaten the employee to prevent them from filing a claim, intentionally delay reporting the injury, or use a company doctor who will downplay the severity of the injury.
These practices are illegal, but can be tough to prove without a lawyer. If you’re trying to get compensation and believe your employer is acting in bad faith, consult with an attorney to figure out your next steps. If your boss is sidestepping you and won’t even tell you how to file a claim, they might not have coverage. In that case, it is possible to sue your employer directly.
If you can’t get anywhere, contact a lawyer
Injured employees can improve their chances of a claim approval by promptly reporting their injury, getting comprehensive medical documentation, following workplace policies, and meeting all deadlines. However, this may not be enough for every situation. Some people will need to call in a lawyer to handle their claim.
While workers’ comp was created to give injured employees access to financial compensation without having to go through a lawsuit, the process isn’t always easy. Getting approved for workers’ compensation can be a challenge, but that hurdle can be overcome by hiring an attorney who knows the system inside and out.
