Top 5 Reasons Your Workers’ Compensation Claim Is Denied

By Peter DePaolis

You suffered an on-the-job injury or developed an illness at work. It is common to expect compensation through workers’ comp insurance because you have a work-related ailment. However, after going through the work to submit a claim, your application returns denied. Don’t worry, legitimate claims receive denials all the time.

However, what you do after receiving that denial will determine whether or not you succeed in your appeal and get the compensation you need for your work-related injury. The first step is identifying why your claim was denied and taking proper measures to correct any issues before you start your appeal.

Why Are Workers’ Compensation Claims Denied for Washington, D.C., Virginia, and Maryland Workers?

Your denial letter should indicate the reason for the denial. However, insurance companies might be vague when it comes to giving you specifics. Some common reasons a claim might be denied include:

The Injury Did Not Happen at Work – or the Employer Says It Did Not Happen at Work

The most common reason for a denial is the injury did not happen at work. To receive compensation, you must suffer an injury or acquire a chronic condition while performing the duties of your employment. If your employer argues that you were not at work at the time or states you were off-duty when the injury occurred, it might lead to a denial of benefits.

Other times, you may not have a legitimate work injury. You might have been injured at home, and in this case, you cannot receive workers’ compensation.

One gray area you might encounter is when you are off company grounds but still performing work-related duties. For example, your boss has requested that you run to the copy center to pick up reports for a meeting and you are on your way to that meeting directly after. In the process, you are involved in a motor vehicle accident.

In this case, you were still performing job duties, even if you were not in your physical place of employment. Therefore, you can get workers’ compensation benefits.

You Did Not Provide Notification in Time

You have specific time limits for filing your claim and reporting the injury to a supervisor. It is imperative that the moment you suffer a work accident or you discover you have a work-related illness, that you report it to your employer.

Then, file your workers’ compensation claim. You typically have under 30 days to file the official application, and failing to do so makes you ineligible for benefits – even with a legitimate workplace injury.

Under the Influence

When you see a doctor and tell them that you are there for a work-related injury or illness, they may test you for drugs or alcohol. This is a test allowed by the state because being under the influence is an exclusion criterion. Meaning, if your alcohol or drug screen were to come back positive and it indicates an intoxication at the time of your accident, you no longer can receive benefits for your work-related accident.

You Failed to See an Approved Physician or Provider

The workers’ compensation system has specific rules for which providers you can see and which providers are not approved to treat work-related injuries. You should consult with the insurance company or your employer for a list of approved medical providers. While you must see this approved provider, you can ensure you still receive the treatment you need to recover by having an attorney represent your case from the start.

You Failed to Seek Medical Treatment

You may have a work injury, but you decided to tough it out rather than seek help. By doing so, you have now made it harder to prove you were injured or that it happened at work. In these instances, the insurance company is likely to accuse you of faking your injuries. Because if you were as severely injured as you claimed to be, you would have sought treatment.

The most important lesson here is to always seek medical treatment after an accident or exposure at work. Doing so starts the record, even if you end up not requiring workers’ compensation benefits later on.

You Received a Denial of Your Claim – What Are the Next Steps?

Now that you understand the reasons for your denied claim, the next step is to make your appeal.

Your denial letter has a strict deadline for how long you have, which falls under state law. Therefore, do not ignore this appeal deadline or you will lose your chance of receiving workers’ compensation for good.

Before launching an appeal, you are encouraged to speak with an attorney. An attorney will review your case, the reasons for the denial, and prepare an argument for the appeal board – if your case makes it that far.

Appeals for workers’ compensation are complicated, and hiring an attorney with experience in these types of cases is your best option. You will have a hearing to attend in front of a judge or member of the workers’ compensation board. You must bring along documentation for your appeal and anything that addresses the denial and proves that the reasons are invalid.

If the insurance company claims you did not seek medical treatment, you may have medical records and bills showing that you did seek treatment the day of the accident. If they try to say you were not working, you might have an email from your boss requesting you run a company errand.

Hire a Workers’ Compensation Attorney for Your Case Today

Whether you need assistance filing a workers’ compensation claim or you need assistance with your appeal, turn to a team of attorneys who understand state laws and have extensive knowledge working with insurers, employers, and appeals boards.

The attorneys at Koonz McKenney Johnson & DePaolis LLP, can assist with your job-related injury or illness. Contact us today to get started by scheduling a consultation with one of our three office locations nearest you or contact us online with your questions.

About the Author
Peter DePaolis joined the firm in 1980 and has since represented a large number of individuals involved in automobile collisions, truck accidents, bus crashes, defective products, and medical malpractice cases. A significant portion of Mr. DePaolis’ practice is devoted to working on behalf of people suffering from asbestosis, mesothelioma, and other asbestos-related cancers. He has led his firm’s fight against the asbestos industry and has recovered over $30 million in damages for asbestos victims and their families.