If you get injured on the job, you hope that your company’s workers’ compensation insurance will support you during your recovery. Injured employees rely on workers’ comp benefits to cover their medical expenses, lost wages, and other losses.
But what happens if you file a workers’ compensation claim and it gets rejected? Insurance claims of all kinds get denied every day for a huge variety of reasons. When it comes to workers’ comp claims, there are some common reasons that claims get denied. Let’s take a closer look at which denial reasons are legit, which are in bad faith, and how to avoid a denial.
Valid Reasons for a Claim Denial
Workers’ compensation claims get denied every day for legitimate reasons. For example, if the injury does not meet the requirements to be covered by the insurance policy, or the claim is filed incorrectly, coverage could be rightly denied.
Some of the potential reasons that a workers’ comp claim may be denied include:
- No medical evidence of an injury
- It was determined that the injury was not related to work
- The benefits on the claim are not covered by the insurance policy
- Out of network care was used
- Pre-existing medical conditions caused the injury
- Horseplay, intentional neglect, or recklessness caused the injury
- The injury was not reported to the employer on time
- A claim was not filed within one year
- Failure to seek medical treatment
- There were inconsistencies in the accident or medical report
- A failed alcohol or drug test
- The employee filed a claim after being fired
Your best bet after having a claim denied is to contact a workers compensation lawyer like those at DiMarco | Araujo | Montevideo. Attorneys who specialize in work injury claims will know the workers’ comp system very well, and can navigate the appeal process for you.
Claim Denials in Bad Faith
“Bad faith” in insurance refers to instances where an insurance company denies a claim that they should have approved. There are many ways in which an insurance company can act in bad faith, according to the bad faith attorneys at Dawson & Rosenthal, P.C.. Some of those ways include:
- The insurance company denied the claim before doing a thorough investigation
- The claim was approved but the payment is being delayed
- There was no reason provided for denying the claim
- The insurance company changed facts or information on the claim
- The policy benefits were terminated but the insurance company did not provide notice
- A third-party company is handling the insurance company’s payments
- A claim was denied for benefits that are explicitly listed in the policy
No matter what the reason is for your claim denial, it’s always best to seek the advice of a workers’ comp lawyer if you believe that your claim is valid.
How to Ensure Your Claim is Approved
Almost 7% of all workers’ comp claims are denied, according to 2017 data from Lockton Companies. This was an increase from 5.8% only four years prior. The BLS has reported that 3.4 claims are filed per every 100 full-time workers every year. This means that tens of thousands of workers’ comp claims are denied every year.
There are things you can do, both before and after filing a claim, to try and improve your chances of approval.
You have 30 days to report your work injury to your employer, and one year overall to file your workers’ comp claim. One year is the California statute of limitations, but it differs per state.
Report Pre-existing Injuries
Make sure to be upfront about any pre-existing injuries. If you fail to disclose existing injuries, it could be considered fraud and your claim will be denied. Always be honest when reporting work injuries and relevant information.
Document everything related to your work injury meticulously. As soon as you experience an injury, you should report it to your boss, take photos of the accident, get witness information, and go to a doctor for a medical evaluation. These pieces of evidence can be used to help your claim get approved.