Workers' Compensation Claim Denials

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Workers' Compensation Claim Denials

Each year, hundreds of thousands of workers nationwide file workers’ comp claims after suffering injuries or developing occupational illnesses while on the job. While many of those injured or ill employees receive the benefits that they request (such as compensated medical care or lost wages), a small percentage of those claims get denied.

Denial rates can vary significantly by state. Anywhere between a single digit to 25% of workers’ comp claims get denied depending on the jurisdiction.

Below, we’ll explain why these denials occur. You can also review our other guides for related information:

Why Workers’ Compensation Claims Get Denied

A denial of a workplace injury claim can happen for any number of reasons. Some reasons for denials include:

You Didn’t Report What Happened Within the Required Timeline

Most states have established timelines during which you must notify your employer that you’ve been hurt and file a workers’ comp claim.

For example, Maryland law spells out that injured workers have 10 days to notify their employers. However, that deadline becomes 30 days for fatalities and one year for occupational diseases.

As another example per the Texas Department of Insurance, there’s a 30-day deadline that applies beginning with the onset of your injury or when you realize it was work-related.

According to the Illinois Workers’ Compensation Commission, you generally have 45 days from the time an accidental injury or occupational illness occurs; however, much like Maryland, this notification time frame may not begin counting down until an actual diagnosis is made or it becomes apparent that it’s work-related.

Given how there’s some variance between states and their notification requirements, it’s important to verify your obligation with your respective state workers’ compensation board so you don’t unnecessarily lose your opportunity to claim these employment benefits.

You Didn’t Receive Medical Treatment

A workers’ comp insurer or board may not believe you’re actually injured or ill if you were never formally diagnosed by a doctor with some type of job-related impairment or occupational disease.

Additionally, if you were diagnosed by a physician other than one selected by your employer, you may face a workers’ compensation claim denial. Why? There are a few states that allow your employer to choose which doctor examines you. For example, Arkansas state law requires you to be seen by an employer-selected doctor. Many states may allow you to see your own choice of doctor in situations like this, though, so it’s best to refer to your local laws and regulations.

Also, if your doctor prescribed a specific treatment plan and you failed to adhere to it, an insurer may dispute its severity and the impact on your ability to work. This can result in a denial of your workers’ comp claim, too.

You’ll want to preserve any records and bills for any health care providers you see as this can aid substantiating your diagnosis and treatment progress.

You Don’t Have a Qualifying Injury or Illness

There may be some conditions that aren’t easily defined as job-related and, thus, readily covered by workers’ comp. In other cases, your employer may claim that your diagnosis pre-existed your employment or that it worsened because of something that happened in your private life instead of in the workplace.

Again, not only medical records, but also eyewitness accounts, photographs, and other pieces of evidence can help you in backing up your claim.

What To Know About Workers’ Compensation Claim Denials

Injured workers tend to mistake a denial letter as the end of the road when attempting to secure compensated medical care or lost wages. It’s not uncommon for injured and ill workers to believe that they’re not entitled to any compensation and return to work before they’re ready.

A lack of understanding of your rights shouldn’t force you back to work before you’re well enough. It can be helpful for workers to seek legal guidance or, at the very least, confer with the workers’ compensation board about options available to them.

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This website was created and is maintained by the legal team at Thomas Law Offices. Our attorneys are experienced in a wide variety of personal injury and work injury cases and represent clients on a nationwide level. Call us or fill out the form to the right to tell us about your potential case. We will get back to you as quickly as possible.