Can My Workers’ Comp Claim Be Denied?

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Workers’ compensation was designed to provide employees with income to pay for living expenses and medical bills while recovering from a work-related injury. However, employers and their insurance carriers have a monetary interest in denying a workmen’s compensation claim. Employers can avoid have their insurance rates increase if they keep claims low. Insurance companies can increase their profits by avoiding large payouts. Some reasons your workers’ compensation claims could be denied include:

Workers’ Compensation claim was filed late.

The most common reason that a workers’ compensation claim is denied is that the employee fails to report the injury immediately. Within 90 days of your injury, you must submit your workers’ compensation claim. If you file your claim after that period has lapsed, employers and insurers can claim that you did not tell the truth about how your injuries occurred or that the injury did not happen at work.

The claim form requires your physician to complete parts of the form. The physician’s account of how your injury could be the result of the accident, as you have described it can corroborate your account of events. However, it is usually best to immediately report any injury to your employer, see a doctor immediately, and submit the claim within the 90 days. 

Injury Was Not Witnessed

Employers often worry about workers making fraudulent claims. If the injury was not witnessed or verified by an objective person like a co-worker or a supervisor, the employer might not believe the injured employee’s story. The insurance company could claim that the injury did not happen the way that you said. 

It is possible that your injury was not witnessed because you were alone in a vehicle or room when it occurred. It does not mean that it did not happen. Be sure to report the injury and recount the events as they happened as soon as possible. See a physician and take pictures of your injuries. Your physician should verify that your injuries are consistent with the type of accident you have described.

Injury Occurred Because of Intoxication

Workers’ compensation benefits are available for workers who sustain an injury while fulfilling their work duties. Benefits should extend to times when they are traveling on behalf of the business or driving to complete a work-related task. The employer may try to claim that you were drinking or taking drugs when the accident occurred.

Even if the work-related injury occurred off-site, an employer is still responsible for providing workers’ compensation benefits. The employer and the insurance company must be able to prove that you were intoxicated at the time of the accident. If you are injured off-site, try to get witness names and phone numbers, and see a physician immediately.

There Was a Pre-existing Injury

If a worker had been injured in a car accident earlier in his history, and later injured his back when picking up a heavy box at work, the insurance company may try to deny the claim, stating that the worker sustained the injury due to the car accident. 

Even if a worker does have a pre-existing injury and an accident at work worsened this condition, this does not disqualify the worker from workers’ compensation benefits. 

The injury did not happen on the job

Your employer might try to claim that the accident did not happen while you were performing work duties. Perhaps you were talking to co-workers and telling them how your injury occurred. They may get the details wrong when relating it to your employer. 

If the insurance company decides to deny your claim, you have the right to appeal the decision. 

  • A notice of intent for mediation or arbitration is sent to your employer and their insurance carrier. You have one week to reach an agreement. 
  • If no agreement is reached, a preliminary hearing is held with the Missouri state workers’ comp division before an administrative judge or in Illinois with the IWCC before an arbitrator.
  • If you are not satisfied with the judge or arbitrator’s decision, you can file a notice to appeal with the state commission within 20 days of the judge’s or arbitrator’s decision. A panel will review the trial proceedings and legal briefs and render a decision. 
  • A trial before the Missouri Court of Appeals would be the next step to appeal further.

There is a short period within which to file your appeal. The appeals process varies from state to state, but generally, an appeal requires a hearing before an administrative law judge through either the state labor department or workmen’s compensation board. 

The workers’ compensation appeals process can be complicated, so you need an experienced workman’s compensation law attorney to help you through each stage of the process. Contact the workers’ comp attorneys at Walton Telken Injury Attorneys for a free consultation.

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