Constitutional Daily
November 2021
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Reasons for a Workers’ Compensation Claim Denial

Sam LarsonSam Larson

After suffering an injury or illness on the job, you may be wondering what to do next. With medical costs adding up and time away from work seeming longer and longer, an injury sustained in or from the workplace can be life-altering. 

If you or a loved one suffered a serious injury or illness while working, you have options. One of the best ways to recover from your injury is filing a workers’ compensation claim or a personal injury lawsuit. While insurance companies should payout injured workers the amount they are owed, sometimes they deny claims. To learn more about why a workers’ compensation claim may be denied, keep reading.

Lack of Evidence

An employer’s insurance company will examine medical evidence prior to determining if a workers’ compensation claim has merit. If there is inadequate evidence or proof of an injury or illness, the insurance company may suspect fraud and deny a claim.

“Medical evidence is one of the most important parts of a workers’ compensation claim,” notes Las Vegas workers’ comp lawyers from Harris & Harris, “that typically includes medical records, test results, doctors’ notes, and any other related documentation.”

The Illness or Injury is Not Covered

Workers’ compensation is only applicable to illnesses or injuries caused during the scope of employment. Scope of employment means any normal job duties or work-related task. If an injury was caused due to unsafe or unmaintained premises at the workplace, such as a water spill that caused a slip and fall accident, this will constitute a valid workers’ compensation claim.

If a worker took a break, such as a lunch break, to take care of personal errands and was injured in the process, the injured personal would not qualify for workers’ compensation benefits.

Lack of Witnesses

A workers’ compensation claim may be denied if there were not witnesses or video proof of the accident or injury. If there are no witnesses and limited medical evidence, an insurance company may deny a claim due to insufficient proof.

Complexities with Pre-Existing Conditions

An employer or insurer may refuse a claim if the injured or ill worker has a pre-existing condition. If a worker had a pre-existing condition, such as carpal tunnel, and broke his or her wrist which made the condition worse, the burden of proof is on the injured worker to prove the accident caused the worsening of the condition

Despite having a existing condition, a worker is still entitled to workers’ compensation benefits if the work-related accident made the pre-existing condition worse. 

Untimely Reporting

One of the most common causes for workers’ compensation claim denial is late reporting. There are various, strict deadlines to report the injury or illness to an employer and to file a claim depending on the state. After reporting the injury or illness, a person typically has one to three years to file a workers’ compensation claim. To ensure deadlines are met, review relevant state laws.

An injured worker may still legally file a workers’ compensation claim after the deadline has passed, but the claim may be rejected due to missing the required employer reporting deadline.

What to Do After a Workers’ Compensation Claim Denial

If you or a loved one was denied workers’ compensation benefits for an injury or illness, you have options. You may file a request for hearing within the state’s time frame to prove your illness or injury or consider filing a personal injury claim. 

Choosing to hire a qualified workers’ compensation lawyer in your area will also help guide you through the complex appeals process and help gather evidence for your workers’ compensation case. Whatever the reason your claim is denied, work with an attorney to help fight for the benefits you deserve.

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Sam Larson
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