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Reasons why workers’ compensation claims are denied

On Behalf of | Sep 2, 2022 | Workers' Compensation Defense |

Workers’ compensation is a no-fault system wherein injured employees receive medical treatment and lost-wage benefits while they are too injured or ill to work. While it covers a wide range of injuries or illnesses, compensation is not guaranteed.  The self-insured employer or insurance carrier may deny a claim, which commonly results in litigation of whether the claim is compensable.

Common reasons for the denial

  • The injury or condition is not causally related.   This defense is commonly raised where the worker has a pre-existing or subsequent injury or condition which accounts for the worker’s current complaints or condition, or the claimant’s diagnosis or condition is inconsistent with the alleged mechanism of injury.
  • The claimant did not sustain an accident within the meaning of the Workers’ Compensation Law.   Some injuries, such as psychological injuries, must satisfy requirements under the law to be defined as an accident to be compensable.   This defense may also be raised if the employer believes that the accident did not occur as alleged, such as the claimant filing a fraudulent claim for an on-the-job accident that didn’t actually occur.
  • No timely notice to the employer of an accident or injury.   Generally, an injured worker has 30-days from the accident to provide notice to the employer; however, there are a multitude of exceptions to this rule.
  • No accident arising out of and in the course of employment.  This is frequently raised where the employer does not dispute that the worker sustained an accident, but the accident did not occur during the course of or in performance of the worker’s job, such as injuries sustained during the commute to work.
  • The claimant was under the influence of drugs or alcohol when the injury occurred.
  • The claimant did not produce medical evidence from an authorized medical provider to support a claim.

Denying a claim

These are just some of the many reasons that a claim may be denied.   If a self-insured employer, third-party administrator, municipality, or insurance company has any reason to believe that a claim should be denied, time is of the essence to file the appropriate denial forms with the Workers’ Compensation Board.   Any questions about whether a claim should be denied and/or procedure of how to properly deny a claim should be promptly directed to a defense attorney to ensure that defenses are properly preserved and that a claim is not improperly established due to a technicality.