What Happens If Your Employer Disputes Your Workers’ Comp Claim?

It’s hard to imagine anyone getting through their work career without a few injuries.

Those injuries can range from a minor paper cut to a serious fall. One injury can be treated with the office first-aid kit, while another requires a trip to the ER. In any workplace injury scenario, you’re entitled to file a workers’ compensation claim to cover your medical expenses and a portion of your salary lost when out recovering.

Workers’ compensation is a state-mandated no-fault insurance program. In other words, you can file the claim regardless of how the accident happened.

However, just because you file a claim doesn’t automatically mean the claim will be approved. Yes, your employer can dispute your claim, which can leave you paying out of pocket for medical bills and missing your weekly paychecks.

Fortunately, if your workers’ compensation claim is denied, you have options, but it will mean bringing in reinforcements in the form of a skilled workers’ compensation attorney. That attorney will be able to help you file an appeal to dispute your claim. If necessary, you could end up before a workers’ compensation board for a final adjudication.

Bottom line: You’re entitled to fight for what you deserve.

Common Reasons Employers Dispute Workers’ Compensation Claims

Workers’ compensation is an insurance program that you don’t pay any premiums, but your employer does. That is a significant expenditure that impacts a company’s bottom line.

As with other insurance programs, when claims increase, premiums may go up. From an employer’s perspective, it is in their best interest to dispute a claim.

There are common reasons why an employer could dispute your claim:

Delayed Notice

If you wait a day or even weeks to report an injury, it can call into question how the accident happened. In other words, if you were hurt on the job, why wouldn’t you tell your boss right away? States also have individual, mandated reporting windows that injured workers must meet. Failure to do so can give insurers grounds to reject the claim.

Outside Job Duties

The keyword with a workers’ compensation claim is “work.” The injury must have happened while you were actively on the job performing your work duties. Your employer can question when the injury happened. Was it during your commute to or from work? If so, then you aren’t entitled to file a claim. You also are entitled to file a claim if you hurt while on an unauthorized break.

Lack of Witnesses

Having a witness to your accident helps. If no one saw the accident, or if there is no CCTV evidence, it becomes hard to verify what happened, and your employer may call the circumstances into question.

Pre-Existing Conditions

Suppose at some point during your employment, you call in sick because of a bad back.

That is totally understandable and common. It also establishes a preexisting condition that could impact your future injury claim. Your employer could dispute your claim because the pain is really from an old injury that has nothing to do with what happened on the job.

Insufficient Medical Proof

If your doctor’s report fails to explicitly state that work duties caused or substantially worsened the injury. You may also have an issue if you receive treatment from a doctor outside the approved network required by the employer or insurer.

That can call your injury into question.

Intoxication

If you test positive for alcohol or illegal drugs at the time of the incident, you would not be entitled to file a workers’ compensation claim.

Horseplay

Many workplaces engage in good-natured hazing or practical jokes. These might even be filmed for social media accounts. However, if you get hurt while you’re “playing around,” you may not be able to file a claim.

Intentional Self-Harm

If an employee is injured in a physical altercation with another employee, they can’t file a claim. The same applies if the worker intentionally hurts themselves.

The Immediate Impact of a Disputed Claim on Your Benefits

A workers’ compensation claim can be disputed at the start of the process or after benefits begin. If there is a legitimate dispute, the weekly wage-loss replacement checks could stop, along with medical treatment reimbursements. The insurer will issue a “notice of contest” informing you that your benefits have stopped.

At that point, the insurer may refuse to pay for ongoing doctor visits or physical therapy regardless of whether you still need those treatments. This can mean you’ll have to pay out of pocket.

Steps to Take If Your Employer Disputes Your Claim

If your employer disputes your claim, you are entitled to appeal against their decision.

It’s important that you continue following your doctor’s orders because you don’t want to exacerbate the injury. You should receive a thorough explanation of why the dispute was issued. Those reasons will be the foundation of your appeal.

At this point, you need to start gathering supporting evidence. That includes saving all text messages, emails, and notes from talks with your boss or the insurance adjuster. It will also help to get phone numbers and notes from people who saw you get hurt. If you can obtain security camera video footage, that will help your case.

Also, collect your timecards to verify you were on the job at the time of the accident.

In order to file an appeal for a denied workers’ compensation claim, you need to complete the correct state appeal forms for your local area.

You must also submit your paperwork on time to avoid losing your right to benefits. It is also vital to talk to a workers’ compensation lawyer. An experienced lawyer can help explain all your appeal options and represent you at a workers’ compensation hearing.

Work Injury Advisor provides resources to help you understand the workers’ compensation appeal process. Just because your employer disputes the claim doesn’t mean your benefits should stop.

You need to explore all your appeal options.