Has your Workers’ Compensation claim been denied? If it has, you should know you DON’T have to take no for an answer!!
The Workers’ Compensation system is complex, and your claim could be turned down for any number of reasons. But what you may not know is that if your claim is denied, you have the right to appeal this decision.
But why was your claim denied in the first place? Here are 10 of the most common reasons why your Workers’ Compensation Claim was denied:
1. Your Injury Did Not Happen At Work
To be eligible for Workers’ Compensation benefits, your injury must have happened while you were performing your job duties.
For example, if you work in a restaurant and twist your knee while taking dishes to the kitchen, it is likely you are owed benefits. On the other hand, if you were injured while you were on your lunch break or on your commute to the restaurant, then you?re most likely not eligible to make a claim.
There is a small grey area around this rule. If you were not at your jobsite but you were at a work assignment or event (like a company retreat), you may have a claim.
You should keep in mind that insurance companies, and even your employer, may work very hard to try to prove that you were not at work when your injury happened, even if you know you were.
In a case where there are no witnesses or CCTV footage, it can be difficult to challenge this decision. However, an experienced Workers’ Compensation attorney can be a powerful force in having this decision reversed.
2. You Did Not Notify Your Employer Of Your Injury Within The Required Time
There are certain time limits in the Workers’ Compensation claim process. After you are injured, it is important that you inform your employer about the injury as soon as you are able to.
If you don’t report your injury as soon as possible, a number of things can happen.
Firstly, your employer will not be able to carry out an accident investigation. This is important for the success of your claim.
Secondly, your employer (and the insurance company) can try to claim you were not really hurt at work. They could argue that if you were hurt at work you would have reported the issue sooner.
Finally, the insurance company can try to claim your injury did not happen due to your job duties. They can try to argue that they were the result of a pre-existing condition or something that happened while you were off the clock.
If you have been hurt at work, tell your employer! If you wait, you might miss out on the benefits you are rightly entitled to.
3. You Were Intoxicated/Under The Influence Of Alcohol Or Drugs
Workers’ Compensation is not about finding someone to blame. However, if alcohol or drugs were involved in your accident, you are NOT entitled to a make a claim.
When you go to the doctor for a work injury, your boss has the right to require that you are tested for alcohol and/or drugs. If tests show that you were under the influence when the injury happened, then your claim will generally be denied.
4. You Were Not Treated By An Approved Medical Provider
Under the Workers’ Compensation system, your boss and the insurance company has the right to provide you with an approved list of doctors you can visit to receive treatment.
In some instances, this may be a negative thing because these doctors can try to downplay your injuries, which means you will receive lower benefits.
Although you have to see an approved medical provider to be entitled to compensation, having the help of a workers’ compensation lawyer will guarantee you the best chance of getting the treatment you require and the benefits you are entitled to.
5. You Never Received Medical Treatment
You do not have to see the doctor for every small scrape or bruise you get at work, but if you think your injury is entitled to a claim, you will need the medical records to prove it.
If you did not receive medical treatment but later try to file a Workers’ Compensation claim, without the supporting medical records, the insurance company can say you faked your injury to claim benefits.
Also, if you put off going to the doctor and you end up being fired or laid off, the insurance company can argue that you are filing a claim to get revenge on your old boss.
Make sure you give your claim the best shot of being successful and visit a doctor.
6. Your Papers Were Not Filed On Time
There are specific time limits and deadlines for when you have to file your Workers’ Compensation claim.
Even for injuries that develop slowly over time, like carpal tunnel syndrome, time limits apply.
If you do not file your papers on time, you are giving your employer and the insurance company another reason to deny your claim.
You are not a Workers’ Compensation expert (and you should not have to be!). If you work with a Workers’ Compensation attorney they will be able to make sure you have all of your papers in order and that they are filed on time.
7. Your Injury Was The Result Of Horseplay, Roughhousing Or Practical Jokes
If you started horseplay at work and ended up getting hurt, it is unlikely that your injuries will be covered. In the eyes of the law, you are not considered working while you are roughhousing. So what can seem like fun and games can end up causing major stress later.
Similarly, if you start a fight at work and you get hurt, you generally will not be eligible for benefits.
8. Your Injury Is From A Pre-Existing Condition
If you had an injury or illness before starting your job (or that is result of an activity outside of your work) and your job did not make it worse, you are typically not eligible for Workers’ Compensation. The insurance company can and will fight very hard to get your claim rejected using this argument.
However, as we already said, Workers’ Compensation claims are complex and there is a lot of gray area. Some employees who are entitled to benefits see their claims rejected and do not fight back. Do not make this mistake.
9. Your Employer Disputes Your Claim
Your employer can, and will, dispute your claim. They may be afraid that the cost of their Workers’ Compensation coverage will increase if there is a claim on their policy. To combat this they could argue that the details of the case are incorrect or that you were not at work when you got injured.
As with reason number 1, this point can be especially true if there are no witnesses or surveillance footage to support your claim. If you were hurt and no one saw it, make sure you tell your employer and co-workers what happened as soon as possible.
You should also get in contact with a lawyer. They will know exactly how to deal with your case, even if your boss is trying to fight it.
10. You Did Not Have A Workers’ Compensation Attorney
You do not have to have a Workers’ Compensation attorney to file a claim, but having one will definitely increase the chances of your claim being successful.
An expert lawyer will be able to guide you through the process and advise you on the different steps and documents you need to give your claim the best chance of being successful.
Having the help of a lawyer will also mean you can focus on recovering and getting back to full health, rather than being stressed by your claim.
If your claim has been denied, then this would be a good time to consider contacting a Workers’ Compensation Attorney (if you have not already). An expert attorney will know exactly what to do. They will be able to give you advice and will improve the likelihood of your appeal being successful.
Disclaimer: For informational purposes only. This is not a substitute for legal advice. If you need legal advice please contact us.
