While nearly all employers in the United States are legally required to provide workers’ compensation insurance, it doesn’t mean that every claim gets paid. Workers’ compensation coverage is designed to protect workers and their families from financial devastation following a work-related injury. Even so, workers’ compensation claims can be denied, and at times, when the claim is paid it is considerably less than the full medical and wage benefits to which you are entitled. Here are some helpful tips on how to proceed if you have been injured and your workers’ compensation claim is denied.
Facts about Workers’ Compensation
- Workers’ compensation insurance, in most states, is purchased by employers from private insurance companies.
- The insurance company handles the claim, approving or denying coverage for wage replacement and medical treatments (surgery and rehabilitation included).
- In many cases, a physician will be recommended by your employer or the insurance company.
- You need to take appropriate steps to preserve your rights and get the compensation you deserve:
- Notify your employer as quickly as possible following your on-the-job injury.
- Complete and submit the claim form supplied by your employer and keep a copy for your records.
- The insurance carrier’s representative will contact you regarding your accident.
- Depending on the rules in your state, you should be eligible for wage benefits replacement in a matter of weeks.
- Don’t stop your medical treatment until your physician clears you to do so.
- If you are partially or permanently disabled, you may be entitled vocational services and a settlement for lost future wages.
The Common Claim Denial Reasons
Worker’s compensation rules vary in each state, but every area has deadlines and requirements which must be met in order to avoid a denial by the insurance company. Keep in mind that insurance companies want to keep the cost down, and make a profit, so claims are often scrutinized and may be initially denied. Determining the reason for the denial is your first step. It should be explained in the denial letter from the insurance carrier. Here are some common claim denial reasons.
- You failed to report your on-the-job injury to your employer promptly. You should notify your employer immediately, or if you suffered a severe injury, as soon as possible. Workers’ compensation coverage doesn’t start until a report is filed. In most states, this deadline is only a matter of days.
- You did not file your claim on time. Keep in mind that reporting your injury to your employer and filing your workers’ compensation claim are not the same action. They are two different deadlines and either can result in denial. The statute of limitations period is different for each state but in most instances, claims must be filed within 30 days of the injury.
- You were not injured while on the job. For an injury to be considered for workers’ compensation, it must occur while on the job either at the job site or off-site on an official assignment for work. For example, if you get hurt getting lunch for yourself or even your coworkers, the injury won’t likely be covered, but if you were picking up lunch for a meeting at work at the direction of your boss, your injury should fall under workers’ compensation coverage.
- Your employer disputes your claim of injury. Your employer can claim the injury is the result of horseplay on the job, it occurred outside of work, that you are faking the injury, or it is the result of a pre-existing condition. You are responsible for proving your injury should be covered by workers’ compensation.
- You were injured while under the influence. No matter what your job description entails if injured while under the influence of alcohol or drugs, your claim will probably be denied. Even if you weren’t drunk, if drinking or drugs (illegal or prescribed) played any role in your injury, workers’ compensation isn’t likely to cover your injury.
- You didn’t seek medical treatment. In most instances, if you didn’t feel your injury was serious enough to seek medical treatment, you should expect your claim to be denied. In nearly all instances, medical treatment is required to receive workers’ compensation benefits.
If Your Claim is Denied
If your workers’ compensation claim is denied, regardless of the reason, don’t hesitate! Call on the expert workers’ compensation legal team at Benn, Haro, and Isaacs, PLLC. We have offices throughout South Florida, with Free consultations for you. Whenever you need it, the team at Benn, Haro, and Isaacs, PLLC are ready with personalized representation to help you get the compensation you deserve following your workplace injury.