A significant number of workers’ compensation claims are denied. Hearing the claim has been denied can send an injured worker into a panic. Understanding the reasons for denials of workers’ compensation claims can help you avoid mistakes and get your benefits.
Understanding Workers’ Compensation
Even though workers’ compensation is a no-fault system, a claim can still be denied. There are rules for who may claim benefits and how benefits are paid. If the claimant doesn’t meet the criteria to claim benefits, a claim may be denied.
Many workers’ compensation claim denials are unjustified. It’s no surprise that insurance companies don’t like paying claims. You may need to challenge the denial of your benefits, and you may have representation from a workers’ compensation lawyer.
Horton & Mendez Injury Attorneys is currently accepting new cases.
Nine Top Reasons Workers’ Compensation Claims Get Denied
1. Missed deadlines
If you’re hurt on the job, tell your employer right away. Tell a supervisor or human resources.
Don’t assume that the company knows about it because coworkers witnessed it or saw you hurt.
In North Carolina, you have 30 days to report a workplace injury. However, you should always report the accident as soon as possible. You then have two years to claim workers’ compensation. Many claims get denied by failing to meet these deadlines.
2. Inadequate medical evidence
Workers’ compensation claims involve physical injury. That means medical evidence. When medical records are lacking, it allows the insurance company to question injuries or what treatment is necessary. Noncompliance with medical care directives may result in a loss of benefits.
3. Pre-existing conditions
Workers’ compensation covers injuries that occur in the scope of employment. Occupational disease may be claimed, too. However, a person may not receive benefits for a pre-existing condition.
That doesn’t mean someone with a medical issue will never receive workers’ comp benefits. Of course, most of us have some kind of medical history. It just means that the program provides benefits for injuries that happen on the job. If you have a pre-existing condition, you may receive compensation if it is made worse by employment. However, pre-existing conditions are generally excluded from benefits.
4. No workplace accident
North Carolina workers’ compensation covers accidents on the job and occupational diseases.
Even if the injury or medical problem occurs while you are at work, North Carolina requires the worker to be able to point to a specific event that was out of the ordinary or unintended. If a workplace accident did not occur, it may be a reason a workers’ comp claim is denied.
5. Medical treatment not sought, not approved provider
In North Carolina, the employer may choose the medical care provider for workers’ compensation benefits. If the chosen provider doesn’t provide benefits in a prompt and reasonable manner, the injured worker can look elsewhere. Failing to get medical care will cause the insurer to question whether there is truly an injury and whether it is the result of employment. Going to an unauthorized provider is another potential reason why workers’ comp would be denied.
6. Horseplay, intentional conduct, intoxication
Even though fault on the part of the employer isn’t required, there are still things that a worker can do to jeopardize their benefits. For example, worker intoxication at the time of the accident is disqualifying as long as the employer didn’t provide the alcohol. Being under the influence of a controlled substance is also disqualifying. A worker may not claim benefits if they cause injury intentionally or willfully.
If an injury results from the employee failing to use a safety measure or comply with an employer rule, benefits are reduced by 10% (N.C. Gen. Stat. § 97-12).
7. No employment relationship
Workers’ comp covers injuries in the scope and course of employment. An employer may say that a worker is an independent contractor rather than an employee. North Carolina law says that an employment relationship may be expressed or implied. When work is casual, and there is no employer-employee relationship, a claim may be denied.
8. False statement in the application process
If a prospective employee makes false statements about their health during the job application process, a claim for workers’ compensation can be denied. For the exception to apply, the employer must have relied on the false representation. It must then be related to the injury. (N.C. Gen. Stat. § 97-12.1).
9. There are second job complications
Today, it’s common for people to work two or even three jobs. It’s the job where you were hurt that is responsible for paying your workers’ compensation. If you apply for benefits through the wrong employer, the claim will be denied. Generally, the second job isn’t considered when determining your wage loss benefits, even if you can’t work either job because of your injuries.
(If you’re not in North Carolina, check the law in your state because there are state differences.)
Taking a second job may impact your benefits, but some benefits may continue. Earn too much, and your wage loss payments may terminate. In addition, your second job may not violate your work restrictions. There are reporting requirements that you must follow. Always consult with an attorney about your specific situation (N.C. Gen. Stat. § 97-2(5)).
Steps To Take If Your Workers’ Compensation Claim is Denied
Start by understanding why workers’ comp was denied. N.C. Gen. Stat. § 97-18(f) and NCIC Form 61 require an employer to provide a detailed explanation if they deny a workers’ comp claim. They should provide a specific explanation rather than just noting “claim denied.” When you know the reasons given, you can respond effectively.
You don’t have to accept the answer. You can use Form 33 to request a hearing. Don’t arrive at your hearing unprepared. Prepare evidence and arguments for your hearing. The evidence may be factual, medical, or both.
Contact an Experienced Gastonia Workers’ Compensation Lawyer
Are you filing for workers’ compensation? Has your claim been denied? Contact an experienced Gastonia workers’ compensation lawyer at Horton & Mendez Injury Attorneys.
