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Strategies to dispute questionable workers’ compensation claims

On Behalf of | Oct 12, 2023 | Workers' Compensation Defense |

Despite common belief, insurance companies approve most workers’ compensation claims, at least initially. Yet, the insurance company can deny the claim later on for various reasons if the insurance carrier is aware of possible later basis for denial and accepts the claim without prejudice to liability.

The employer must openly communicate with the insurance company

Employers should tell the insurance company as soon as they suspect a claim is not valid. Timeliness is critical as the insurance carrier has short filing deadlines for accepting versus denying a claim.  The employer should file the claim, and the insurance company will take their statements into consideration in determining whether to accept the claim with prejudice, accept the claim without prejudice, or controvert the claim outright.   It is also critical that the employer provide complete and accurate answers in reporting a claim to the carrier, as an inaccurate filing could ultimately result in prelusion of a defense or evidence.

Insurance adjusters rely on employers’ communication to know where to focus their investigation. If the employer doesn’t talk openly with the insurance company, the adjuster might miss important details. This can affect whether the employee’s injury is compensable.

Claims that start off as compensable can sometimes change

In some limited circumstances, an employee’s workers’ compensation claim can start off as compensable but change later on. For instance, an employee hurts their back at work and their workers’ compensation claim gets accepted without prejudice to liability. Later, after a month, the employee informs their doctor that they pulled a muscle in their back while gardening on the weekend before the injury at work.   In this scenario, the insurance carrier may be able to withdraw the acceptance of the claim and move forward with a claim denial.

In the alternative, even if the insurance carrier cannot withdraw the acceptance of the claim outright, there may be other remedies available to minimize liability for the claim.

There are many people who are injured at work, and workers’ compensation exists to protect the employee and the employer.

It is critical for employers to remain alert and take an active role in preliminary reporting of and cooperation in investigation of workers’ compensation claims. Employers must take the time to evaluate the circumstances and always communicate openly with the insurance company.