5 Reasons Workers’ Compensation Claims Are Denied

Oct 20, 2021

Workers Compensation Claim Denied: Unveiling the Facts

Workers’ comp claims are most frequently denied when a workers’ comp insurer believes an excluded hazard caused your injuries. For example, they might suggest you were injured while you were off the clock and, therefore, weren’t covered by your employer’s workers’ comp policy.

The above “reason” is an explanation the insurance company might give you for why your claim was denied. The motivation for denying claims is the insurance company doesn’t want to lose the money, and your employer doesn’t want their workers’ comp insurance premiums to go up.

Both employers and insurers have a strong monetary incentive to deny you a workers’ comp claim, regardless of the claim’s validity.

Why Workers’ Comp Claims Are Bad for Employers

  • Workers’ comp policies might have a deductible, which means your employer will have to pay some of your costs out of their pocket
  • Workers’ comp claims, especially multiple claims, can result in significant premium increases for your employer
  • Most employers don’t want their employees to miss work, especially since they can’t legally fire a worker for filing a workers’ comp claim, and hiring a temporary replacement often isn’t feasible or cost-effective

Reasons the Insurance Company Doesn’t Want to Pay Workers Compensation Benefits

  • Claims represent a loss for insurance companies, so if there’s some way for them to deny a claim, they’ll find it
  • Serious injuries require expensive medical treatment, rehabilitation, months of wage compensation, and other potential forms of compensation
  • There are scenarios in which you might be eligible to receive workers’ comp benefits for many years

Workers’ comp insurance companies have a greater incentive to challenge serious injury claims that will result in high claim costs.

Most Common Workers’ Comp Claim Denial Reasons

 1. The Injury Didn’t Happen at Work

These disputes are more common than you may realize. Do you have a legitimate workers’ compensation claim if you’re injured on the sidewalk in front of work before your shift? What about when you’re leaving for the day? What if you’re injured in the parking garage after your shift? Or you’re working from home when you’re injured?

There are a lot of scenarios where disputes could arise over whether your injury truly counts as a workplace accident.

 2. You Were Doing Something That Disqualified You From Receiving Compensation

Horseplay and intoxication are some of the most common causes of claim denials. If you were messing around at work and are injured, your employer and their workers’ comp insurer will argue that you weren’t performing your duties when the injury occurred. They’ll point out that you broke the rules specifically in place to prevent injuries from occurring, and it may even give them grounds to terminate your employment.

 3. You Didn’t See the Right Doctor

The only way to win a successful workers’ comp claim is to report it to your employer through the proper channels and then see an approved doctor from their panel of physicians. That panel doctor’s assessment will have the most significant impact on your eventual claim. Going to see your own doctor or failing to see a doctor at all will likely make it difficult or impossible to win your lawsuit.

 4. You Missed Deadlines

In most cases, Georgia’s workers’ compensation statute of limitations is one year. Some scenarios may extend the deadline to two years, like if your employer paid for your medical treatments or paid temporary partial or permanent disability benefits.

This relatively short statute of limitations can complicate things if your injury is degenerative or cumulative, like developing carpal tunnel over time due to your job duties.

Fast action is vital if you’ve suffered a workplace injury. It’s likely best to speak with a workers’ comp lawyer as soon as possible.

5. Your Injury Was Idiopathic or Caused by or Exacerbated by a Pre-existing Condition

Your employer and their workers’ comp insurer can’t be forced to pay for conditions or injuries you suffered before beginning your job or injuries due to a pre-existing condition unrelated to your job.

Generally, workers’ comp will only cover an injury sustained because you were performing your job duties. If you had a knee injury from playing sports in high school, which made you fall and injure yourself at work, your workers’ comp claim might be denied.

An idiopathic injury is one that couldn’t have been predicted but also wasn’t job-related. If you have a seizure at work and hit your head on the floor, your workers’ comp claim might be denied since your employer and your job didn’t contribute to the seizure.

However, there are often disputes in those types of claims, and you might succeed in getting your claim settled in an appeal. Talk with a workers’ comp attorney before assuming a claim denial is the end of the case.

Overcoming Workers’ Comp Denials

Receiving a denial for your workers’ comp claim can be disheartening, but it doesn’t have to end your pursuit of compensation. Understanding the denial reasons and what steps you can take can equip you to challenge the denial effectively. If your workers’ comp has been denied due to any of the above reasons, here’s what you can do:

  • Seek Legal Counsel: A workers’ compensation attorney experienced in workers’ compensation issues can help you understand your denial and guide you through the appeal process.
  • Thorough Medical Evaluation: Ensure you get a thorough medical evaluation and keep all medical records safe. These serve as crucial evidence for your claim.
  • Report your Injury Promptly: Timeliness is critical in workers’ comp claims. Report any work-related injury to your employer as soon as it happens.
  • Follow Instructions: Comply with all instructions, including seeing the approved doctors for your medical evaluations, to avoid giving insurers a reason to deny your claim.
  • Document Everything: Maintain a detailed record of the incident, medical treatments, communication with your employer or insurer, and how the injury has impacted your life.

While there are no guarantees that a denied claim will be approved after you challenge it, understanding the common reasons for denial and taking action to address them can significantly increase your chances of success. If you need help navigating your legal rights in a workers’ comp case, contact an experienced workers’ compensation lawyer who can guide you.

Get Help With Your Work-Related Injury or Illness in Atlanta

The workers’ compensation system exists to protect injured workers. Having your claim denied can be disconcerting and leave you feeling vulnerable, but you’re not alone. The experienced Georgia workers’ comp lawyers at the Dressie Law Firm are here to answer your questions about the law and why a claim was denied.

Our team understands the complexities of workers’ compensation laws and how to navigate them to maximize your chances of getting the benefits you need. We will explain every step of the legal process and aggressively fight for your rights if we think moving forward with an appeal is necessary.

If your injury happened at work and you want to challenge a denied workers’ comp claim, don’t wait. Contact us today for a free case evaluation, and let us help you on your path to recovery.