Workers Compensation

Common Reasons Workers' Compensation Claims Are Denied

By Carey Worrell, Attorney (J.D., Harvard Law School)
Find out some of the top reasons for a workers' compensation denial.

Have you received a denial letter from workers' comp? If you have been injured on the job, you are probably entitled to compensation for your injury and your lost time from work. Workers’ compensation is a no-fault system, which means that most workers who are injured at work while performing work duties are entitled to benefits. However, most of the time, these benefits are funded by insurance companies. This means that the insurance company is typically the one deciding whether your claim is accepted or denied.

Here are some of the top reasons that workers’ compensation claims are denied. (To learn how workers fare after receiving a denial, see Denied Workers' Comp Claims: How Can I Win Benefits After a Denial?)

Delay in Filing Your Workers' Comp Claim

In order to be eligible for workers’ comp benefits, you must meet certain deadlines for notifying your employer of your injury and filing a workers’ compensation claim. For example, in California and Texas, a worker has 30 days to report an injury to an employer without risking the right to collect benefits. However, in Connecticut, a worker must report a workplace injury immediately.

Many states have separate time limits for actually filing the workers’ comp claim paperwork. In Texas and Connecticut, a worker must typically file a claim within one year from the date of an accident or injury. In California, the worker must file within either one year (if the insurance company didn’t pay out any benefits) or five years (if the insurance company paid out some benefits on the claim). For more on your state’s rules, see State-Specific Information for Workers' Compensation.

Insurance companies are often suspicious when a claim is filed several weeks or months after the injury happened, with no prior notice. To avoid your claim being denied for this reason, it’s best to notify your employer of your injury right away and follow up by filing a claim as soon as possible.

Off-Site Injury

Claims are also commonly denied if your employer, or the insurance company, believes that your injury did not happen at work. To qualify for workers’ compensation benefits, you must be injured in the “course of employment.” Typically, this means being injured at the workplace while you are performing work duties. So, if you were injured outside of work and you weren’t conducting any business for your employer, your claim may be denied.

Injuries that happen while you’re commuting to and from work typically aren’t covered. However, you may be entitled to workers’ compensation benefits if you were traveling to a work function or conducting business at the time of your injury. For example, if you stopped by a bank to cash a check for your employer on your way in to work, and you slipped and fell in the bank, you can probably still collect benefits.

Preexisting Injury

The insurance company may also try to limit your claim if you had a preexisting injury to the same body part that was injured in your workplace accident. For example, suppose you have a back condition due to a previous car accident and then further injure your back while picking up heavy boxes at work The insurance company may try to pin the majority of your injury on the previous car accident, in order to minimize the amounts paid out in workers’ compensation benefits.

In general, having a preexisting injury does not disqualify you from receiving workers’ compensation benefits. In most states, including California and New York, workers’ comp will only cover any worsening of your condition caused by the work accident.

Misconduct

Although workers’ comp is generally a no-fault system, certain injuries are considered outside the scope of employment. For example, workers’ comp generally does not cover injuries that are self-inflicted or caused by the use of drugs or alcohol. Similarly, injuries caused by practical jokes or horseplay are often not covered, unless the employer knew about and tolerated this type of behavior in the workplace.

Insurance companies routinely deny claims when they can point to any sort of misconduct on behalf of the injured worker. However, whether misconduct is severe enough to result in disqualification depends on the circumstances of each case.

Minor or Fully Healed Injury

A workers’ comp claim may also be denied if it looks like your injury was not serious enough to require medical treatment or time off from work. For example, if you were injured at work and tried to work through the pain rather than get the treatment you need, that may lead an insurance company to believe that your injuries aren’t as serious as you claim. The best way to combat this type of denial is to get treatment for your injury as soon as it happens and tell the doctor that it happened at work.

If a doctor says that your injury has healed enough for you to return to work, claims for additional benefits may be denied. For example, if you break your arm at work, you are probably eligible for medical benefits and temporary disability benefits while your arm is healing. However, if your doctor decides that your arm is fully healed and you have no limitations, any claims for permanent disability benefits will likely be denied.

What to Do About a Denied Claim

As with many other forms of insurance, workers’ comp insurers often deny claims to keep their own costs down and maximize profit. While some of the reasons listed above may be legitimate reasons to deny a claim, insurance companies also routinely deny claims just to see if they can avoid paying out benefits.

If you think your claim was denied wrongfully, you may appeal the decision with your state’s workers’ compensation agency. However, you will need to file your appeal within the time limits required by your state. For more information, see our article on appealing a workers' compensation denial.


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