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6 Common Reasons Workers’ Compensation Claims Are Denied

May 17, 2023 | Personal Injury,Uncategorized,Workers' Compensation,Workplace Safety

Workers’ compensation is intended to be beneficial for workers and companies, and the system should be easy for employees to navigate. The keywords there are should be. Even though workers’ compensation insurance is an expected expense for business owners, workers’ comp insurance companies don’t always process claims in good faith. Completely legitimate claims may be denied, leaving injured workers feeling hopeless and confused. Keep reading to see some of the most common reasons claims are denied.

If a denied workers’ compensation claim has thrown a wrench in your financial stability, let us help. Don’t worry about coming to us—we meet over Zoom and process documents with DocuSign, so you never have to leave the comfort of home. Call Pisegna & Zimmerman at 818-888-8888 to set up a consultation now.

Unusual Number of Fraudulent Cases

If your place of employment has had an atypical number of fraudulent cases, their insurance provider will start taking a closer look at every claim they send in. Insurance providers keep substantial documentation on every company they serve, and if one company has an abnormally high amount of claims, yours could get caught in the crossfire. Any red flags they find, no matter how innocent they actually are, could get your claim denied.

Previous Workers’ Compensation Claims

Ideally, previous workers’ comp claims would not impact future claims. However, this simply isn’t the case. If the same employee seems to file continuous workers’ comp claims, both the employer and the insurance provider may look a little deeper. They may be concerned that the employee is falsifying their injuries to get paid time away from work, that the employee is using workers’ comp for non-work injuries, or that a frequently injured employee is a danger to themselves or others.

Minimal Information Provided

When you file a workers’ compensation claim, you must provide all the information that they ask for. This generally involved going into detail about the accident, what injuries it caused, and what type of care you have received. When employees decline to provide requested information or companies don’t provide all of the information to their insurance company, it may result in a denied claim.

Evidence Does Not Support the Claimed Injuries

After you’ve submitted the information for your claim, the insurance company will investigate your injury and the information you’ve supplied. In particular, they will be looking at the medical records from your injury and determining whether or not they match up with your retelling of the accident. If there are any discrepancies, they will look into it more extensively before approving or denying the claim. For example, consider someone who says that they slipped and fell at work, which caused them to break their leg. The video shows a relatively minor fall that the person was able to get up and limp away from. A subsequent doctor’s visit several days later revealed a bone broken in multiple locations, an injury that would have required far more force than what was seen on the surveillance video. In this scenario, the insurance company would likely worry that the injury happened outside of work and that the employee was trying to pin the break on a previous fall.

The injury Did Not Happen at Work

As we’ve mentioned multiple times so far, insurance companies are always on the lookout for injuries that aren’t actually work-related. Consider how much that would cost a company—they would be covering the medical costs and partial wage replacement for an injury that did not even occur on their property. The insurance company will scrutinize claims to ensure that the injury actually occurred at work and in the course of your regular work. Certain red signs will make your claim more likely to be denied:

  • Your workplace has lots of surveillance cameras, but your injury occurred in one of the very few places without surveillance
  • You waited days or weeks to seek medical attention for an injury
  • The injuries you sustained do not align with the type of work you do

Waited Too Long to File a Claim

You have a short window in which to begin your workers’ compensation claim. If you wait too long or if your company delays the processing of your claim, you may be automatically denied.

Was Your Workers’ Compensation Claim Denied? Call Pisegna & Zimmerman Now

After a workers’ claim denial, you may be worried about paying for your medical care and getting your income back. We can help you fight for the benefits you are owed. With our Zoom consultations and DocuSign capabilities, you can meet with our worker’s compensation lawyers from anywhere you feel comfortable. Call us at 818-888-8888 or reach out online to schedule a consultation now.