Why Your Workers’ Comp Claim Is Denied and What Should Be Your Next Steps

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It is not unusual for claims to be denied by your employer’s insurance company. However, there are some common reasons why your claim will be denied.

The injury was pre-existing

A pre-existing injury can often disqualify you from filing a workers’ compensation claim. This is one of the most common answers if you were to ask this question: why was my workers’ compensation claim denied? When you first got injured, it was probably not due to your employer’s negligence—that didn’t happen until later. Workers’ compensation insurance companies can argue that because your injury happened before you were employed by them, they are not responsible. Though this sounds personal and subjective, if your occupation brings about an increased risk for specific types of injuries, then the insurance provider may still be liable for those injuries. This means that if other people in your same profession have experienced similar injuries within a short period, this may demonstrate sufficient evidence to prove the correlation between work and your condition (though given other factors such as other preexisting conditions, it will never be 100% conclusive).

The injury wasn’t work-related

Your employer is not responsible for injuries that do not occur at the workplace. This includes commuting to and from your job location, as well as any duties you perform away from your official workplace. Injuries caused by a defective product or unsafe working conditions are also considered non-work related unless it can be proven that they occurred because of negligent safety precautions on behalf of your employer.

You were injured intentionally

The law does not protect employees who injure themselves on purpose or who cause their own accidents while under the influence of drugs or alcohol. However, there are some exceptions to this rule; if the behavior causing the accident was reported before it happened, an insurance provider may still be held liable for injuries incurred due to a reasonable response to a foreseeable scenario.

You were intoxicated

If your intoxication was the result of drug or alcohol use, the law will presume that you bear some responsibility for what happened. However, if your employer caused you to be inebriated on the job (i.e., by forcing you to drink with them), such circumstances may constitute an exception—though again, this is difficult to prove and often comes down to personal interpretation by the insurance provider’s team of investigators and attorneys.

What You Should Do When Your WC Claim Has Been Denied

You may think that these are all good reasons for denying your workers’ compensation benefits but they are not. So, what should you do when your claim has been denied? 

File an appeal with the insurance company

If your workers’ compensation claim is denied, you will need to file an appeal. Your first step should be to request an explanation of the reason for denial from the insurance company. Failing that, you will need to seek legal help in filing an appeal with the insurance company. You have only 30 days by law to send a written notice of denial so do not delay! Be sure to have clear records of your attempts and responses, keeping all documents related to your case. You will also want paper records such as copies of your documentation and medical records. If you do not file an appeal within 30 days of the denial, you may lose your right to appeal or obtain benefits for any subsequent disability or injuries related to your on-the-job injury.

Hire a lawyer 

Contacting a workers’ compensation lawyer who can appeal the decision is very important. Factors that will be taken into account are how many times your claim has already been denied, whether or not you have presented any new evidence for this case, and what type of errors were made when the initial decision was reached. 

File a lawsuit against your employer 

You should file a lawsuit against your employer when he or she denies your workers’ comp claim. A suit will hold them accountable for any actions against you and ensure that the insurance company has to pay what is rightfully owed to you. As mentioned earlier, hiring a workers’ compensation attorney can help you review lapses in your employer’s decisions and take legal action immediately.

If you’re filing a lawsuit against your employer, it means that you are essentially telling the world that your claim is valid. You should be prepared for this and take precautions to ensure that no outside sources can jeopardize your legal suit; this could include anything from talking face to face with your attorney only instead of using the phone, to locking down your Facebook account so potential evidence cannot be shared on there.

The most important thing to remember is that even if the worker’s compensation insurance provider denies your claim at first, it doesn’t mean you can’t fight back. You may be able to appeal the decision and file a lawsuit of your own—so whenever possible, seek legal counsel from an attorney who specializes in such matters. A lawyer will help you determine what kind of evidence and testimony will work best on your behalf and do their best to represent not just your interests but those of all injured workers.