5 More Reasons Why Workers’ Comp Claims Get Denied

Workers’ compensation claims are denied by insurance companies each day. Not all of those reasons for denials are expected, though, and some are not even valid under the policy’s terms and conditions.

In a previous blog entry, our legal team from the Law Offices of Wax & Wax in Santa Clarita discussed five common reasons why workers’ compensation claims are denied. To share even more knowledge about workers’ compensation claims, we are going to take a quick look at five more common reasons why workers’ comp claims get denied by insurance companies.

Incorrect Medical Provider Treated You

Depending on where you work and possibly on the details of your workers’ compensation coverage, you might be required to see only a select few medical providers after an on-the-job accident. Seeing an out-of-network or unapproved medical provider for your initial care can invalidate your claim at worst and complicate it at best. You might have the option to switch to your own doctor later, though.

Delay When Filing Paperwork

When it comes to deadlines, workers’ compensation insurance providers are sticklers, to put it nicely. If you miss a filing deadline, then you can expect beyond a doubt that the responding insurance company will use that as a chance to deny your claim. As with many other factors involved in a workers’ compensation case, the statute of limitations to file a claim or respond to inquiries will change depending on your home state. Work with a local attorney to learn more about the rules and laws specific to your case.

Inappropriate Work Behavior

Workers’ compensation benefits are meant to help workers who have been injured at work due to an accident. Even if your own mistakes contributed to your accident, you can still file for workers’ comp. One of the few exceptions is if you were intentionally causing trouble or acting recklessly when you were hurt. In other words, you must be acting responsibly or reasonably while working in order to qualify for workers’ comp benefits.

For example: Johnny is racing up and down the stairs at work because a coworker dared him to complete as many laps as he could in the least amount of time. He trips on the stairs and suffers a serious fall injury. If it is known that he was engaging in horseplay when he was hurt, then he would likely be ineligible to file for workers’ comp. A defect in the stairs, like a lifted piece of carpeting or metal that caught Johnny’s foot, could change the case’s outcome, though.

Preexisting Medical Conditions & Injuries

A favorite tactic among insurance companies is denying workers’ comp claims by saying the claimant’s injuries are preexisting and unrelated to the workplace accident. The trouble is that preexisting conditions are present in a lot of workers’ comp claims, but that does not mean that they should invalidate a claim. Instead, preexisting conditions are often exacerbated by a workplace accident, rather than being directly caused by it. When a preexisting condition is worsened, the claimant should still be eligible for benefits.

Proving that your injury was not preexisting, or that it was but became worsened in your workplace accident, can take some work. Your medical records can be a powerful tool to prove a point when in the right hands. If you aren’t sure how to build your claim and use evidence where available, then you should team up with a workers’ compensation attorney.

Unexpected Legal Complications

It can be difficult to predict gray areas in the law when you are filing and managing a workers’ compensation claim, especially if you are not familiar with the legalese behind the average case. An unexpected legal complication can arise that jeopardizes the validity of your claim. Reacting the wrong way or after waiting too long could spell disaster for any recovery you were hoping to make.

To prepare for the unexpected, you should team up with a workers’ comp lawyer at the start of your claim. Give them permission to work on your behalf, navigating and progressing your claim while you focus on rest and recuperation.