Workers' compensation benefits represent a critical financial lifeline when you suffer a serious work-related injury. This is especially true if you must deal with substantial medical bills and lost wages when you cannot work.
Unfortunately, it’s all-too-common for valid workers’ comp claims to get rejected. If you find yourself in that stressful situation, remember that getting a denial isn’t necessarily the end of the road. You likely have the legal right to appeal the denial decision, support your claim with more evidence, and convince the insurance company to approve payment of the benefits you deserve.
However, overturning a worker’s comp denial can often require persistence, attention to detail, and a solid understanding of the law.
An experienced workers’ compensation lawyer can analyze why your claim was denied, review the best options for building a solid case, and represent you in appealing the decision.
Why are denials of workers’ comp claims so common?
Laws in most states generally require (or at least strongly encourage) employers to purchase workers’ compensation insurance. Employees who suffer work-related injuries or illnesses have the right to submit a claim under that insurance for medical and disability benefits.
In theory, it should be quick and easy for an injured or sick worker to obtain workers’ comp benefits. In practice, however, it’s often anything but. Here’s why.
Insurance Companies Have Incentives to Deny Claims
Insurance companies that sell workers’ comp policies to employers profit by collecting more money in premiums than they pay out in claims. The less they pay in benefits to injured workers, the more they keep, and the more profitable they are.
There’s nothing inherently wrong with that business model. Insurance is beneficial to spread risk and protect against the worst consequences of unexpected events. And no one expects insurance companies to be charities or pay claims without investigating them for fraud or other abuse.
But to improve their bottom line, some workers’ comp insurance companies will push the envelope on investigating and denying claims. They will try to find any reason to say no to an injured party’s claim for benefits, no matter how technical or unfounded.
They feel confident in taking aggressive positions because many workers will give up on a claim once an insurer issues an initial denial, even if the claim is valid and would be approved if appealed.
Insurance laws restrict the ability of insurance companies to engage in unfair claims practices and a company that violates those laws risks fines and other penalties. But unfortunately, not all violations get flagged, and the law often leaves insurers plenty of room to deny claims for trivial or frivolous reasons.
Employers Have Incentives to Limit Workers’ Comp Claims
Most employers comply with their obligations to purchase workers’ comp insurance for their employees. But that doesn’t mean they like doing it.
Given the opportunity, some employers will do everything they can to make it difficult for injured employees to apply for or receive workers’ comp benefits.
Employers may, for example:
- Dispute the facts and circumstances alleged in the employee’s claim;
- Make it difficult for the employee to obtain information about workers’ comp rights or to submit the paperwork necessary for a workers’ comp claims;
- Slow-walk parts of an employee’s claim submission over which they have control;
- Force employees to use employer-friendly medical providers who give favorable diagnoses or limit employees’ treatment options;
- Punish employees who pursue workers’ comp claims by cutting their hours, assigning them unpleasant tasks, or taking other adverse job actions.
These tactics can undercut the likelihood of an employee’s initial claim getting approved.
Why do employers resort to these tactics? There are several common reasons.
- To avoid higher premiums: Employers have to pay premiums for their workers’ compensation policies. These amounts are calculated based on their loss history-that is, how many workers’ comp claims employees have filed and how much money the insurance company has had to pay in benefits. The fewer and lower the claims against an employer’s policy, the lower the premiums-and thus, the stronger the incentive for an employer to dispute claims or make the claims process difficult.
- To discourage other employees: By pursuing a strategy to keep premiums as low as possible, employers pressure workers to think twice before filing a claim. If you think the process of claiming workers' comp is complicated and likely to include a lengthy appeal, you may not even bother to pursue benefits.
- To shield the company from regulators: Sometimes, the circumstances surrounding an employee's injuries may point to unsafe working conditions that violate workplace safety regulations that may lead to fines and other sanctions for the employer.
To be clear, none of these reasons is valid, and employers use many improper and even downright illegal tactics to undercut their employees' workers' comp rights.
Employers who stand in the way of their employees’ legitimate claims for workers’ comp benefits risk breaking the law. Unfortunately, that doesn’t always stop employers from trying, and if they succeed, it often leads to workers’ comp insurance companies denying valid claims.
Common Reasons Given for a Workers’ Comp Claim Denial
Workers’ comp insurance companies must give you an explanation for denying your claim. But the reasons they give aren’t always valid, accurate, or fair. Here are some common justifications workers’ comp insurers use when refusing to pay you the benefits you deserve for your workplace injuries.
Workers' comp insurance doesn't cover you
#I. Some insurance
companies may deny your claim based on the assertion, often incorrect, that you do not qualify as an employee covered by workers' comp insurance. With the help of an experienced workers' comp lawyer, however, you can often present evidence that your conditions of employment, such as your work schedule and job responsibilities, make you eligible for benefits.
#II. You’ve missed a deadline
Applying for workers' compensation benefits entails meeting deadlines set by law, regulation, or the terms of an employer's workers' compensation insurance policy. Workers' comp insurance companies often justify claim denials on missed deadlines-in some cases, even if you did not.
Generally speaking, the longer you wait to pursue a workers' compensation claim, the more likely employers are to dispute claims and insurance companies to deny them, so start as soon as possible with the help of an experienced attorney.
#III. Your injuries aren’t work-related
Workers' compensation benefits are specifically for injuries and illnesses that you suffered in connection with performing duties that fall within the scope of your job. So, workers' comp insurance companies will seize on any fact they can to claim that you did not get hurt or sick at work. In many cases, they simply get their facts wrong.
Sometimes, they will misinterpret your medical records or take something you said to your doctor out of context to insist that you had a pre-existing condition. An experienced workers’ comp appeal lawyer can help you push back against these mischaracterizations and get you the money you need.
#IV. The medical evidence does not prove your injuries
Workers’ comp insurance companies frequently demand objective proof of your injuries or illness. Sometimes, they will deny claims because they deem your medical records insufficient to document your claim or its connection to your work.
Cumulative trauma injuries like carpal tunnel syndrome and lower back pain, in particular, will often be denied for this reason. By working with a skilled workers’ comp attorney, you can collect the necessary evidence to substantiate your claim on the first try, or on appeal.
#V. You are not disabled/you can still work
Workers’ comp benefits commonly include partial replacement of the wages you could not earn because a work-related illness or injury prevented you from working. This gives workers’ compensation insurance companies a strong incentive to question whether you are truly disabled by your condition.
Insurers regularly deny claims for disability benefits by insisting that, despite your injury or health problems, you can work or will be able to work sooner than your doctor advises. An experienced attorney can develop the evidence you need to prove to the workers’ comp carrier that you were and are truly disabled during the period you claim for disability benefits.
#VI. Workers’ comp doesn’t cover your medical provider or treatments
In some states, workers’ comp insurance companies can deny benefits if you sought care from a doctor who was not on the insurer’s or your employer’s list of approved providers. Insurers also routinely refuse to pay for certain types of medical treatments, even if your doctor recommends them in your case.
Consult an experienced workers’ comp attorney promptly if the insurance company denies your workers’ comp claim for either of these reasons. Your ability to get the care you need may depend on taking quick action to protect your rights.
#VII. Your wrongful behavior caused your injuries
Workers' compensation insurance may not cover injuries attributable to your misconduct, such as getting hurt while under the influence of drugs or alcohol or if you intentionally caused your injury. But insurance companies usually cannot deny your claim simply because you made a mistake on the job, even if you were careless.
Still, workers’ comp carriers will try to blame your supposedly wrongful conduct whenever they can. A skilled workers’ comp lawyer can protect you from these accusations and get you the necessary benefits.
Appealing a Denied Workers’ Compensation Claim
Regardless of the reason the insurance company gives for denying your workers’ comp claim, you have the right to file an appeal of that decision. But that doesn’t mean that winning an appeal is something you can, or should, handle on your own.
The process of appealing a workers’ comp denial varies from state to state. In some states, it involves submitting an appeal to the insurance company for a review and then a subsequent appeal to a state administrative agency.
In other states, the appeal gets submitted directly to the administrative agency. Once in the hands of a state agency, an appeal usually ends up in a hearing. An administrative law judge decides whether to approve your claim.
No matter what specific process is applicable in your workers' comp appeal, having an experienced workers' comp attorney on your side can make all the difference in the outcome. Workers' comp appeals often involve a complex array of rules, deadlines, and evidence requirements that can confuse and trip up someone who tries to appeal on their own.
Putting those tasks in the hands of a skilled advocate who represents clients in workers’ comp appeals regularly gives the best possible chance of overturning the insurance company’s decision and getting your benefits paid as soon as possible.
How to Increase Your Odds of Overturning Your Workers’ Compensation Claim Denial?
A denial of a valid workers' comp claim can feel demoralizing and frustrating. But the good news is that you can increase the odds of a more favorable outcome for your appeal by taking a few simple steps.
Follow medical advice and keep getting medical treatment
Workers’ comp is supposed to pay for your medical care after getting hurt or sick at work. So, if the workers’ comp insurance company denies your claim, you might understandably worry about paying for care.
Try to stick with your medical treatment plan as closely as possible. Your health and wellbeing are important. And, unfair as it sounds, if you stop doing your best to take care of yourself and to seek medical care, the workers’ comp insurance company might hold it against you in your appeal.
If cost is a concern, let your medical provider know about the difficulty with workers' comp. Many providers will agree to work with you to help you afford your care while your appeal is pending. An experienced lawyer may also be able to help you work out an arrangement with your medical provider.
Assume the workers’ comp carrier will continue to look for reasons to deny your claim
One of the best ways to help your case is to be mindful that the workers’ comp insurance company is still paying attention to you. The insurance adjuster will keep tabs on what you say on social media or to coworkers about your injuries. The insurance company may even send an investigator to take photos or videos of you doing day-to-day activities.
So, be careful with what you say and do. Stay away from social media if you can. Don’t discuss your injuries with your coworkers. Do not put yourself in situations where you may make your injury worse. And try to avoid activities that might cause someone to question whether you are injured.
Contact a Workers’ Comp Attorney as Soon as Possible
Obtaining workers’ comp benefits involves taking important steps at specific times. The best way to maximize your chances of getting paid the benefits you need is to seek the help of an experienced workers’ comp lawyer as soon as you know you’ll need to seek benefits.
But if you didn’t have a lawyer’s help with your initial claim, and the workers’ comp insurance company denied it, now is the time to connect with an attorney. Appealing your denied workers’ comp claim will require meeting deadlines, collecting records, following procedures, and presenting evidence. Most people in your shoes will need an experienced attorney to handle those tasks successfully.
Was your workers’ comp claim denied? Contact an experienced workers’ comp claim denial lawyer in your area today.