Common Reasons Workers’ Compensation Claims Are Denied

Published on Apr 2, 2024 at 7:50 pm in Workers Compensation.

Common Reasons Workers’ Compensation Claims Are Denied

Workers’ compensation serves as a crucial safety net for employees who experience workplace injuries. 

It’s designed to provide financial assistance and medical benefits to workers who suffer injuries or illnesses on the job. However, not all claims are approved, which can leave employees in a difficult, and often frustrating position.  

Understanding why claims are denied can help employers and workers navigate the system more effectively.  

Let’s take a look at some common reasons why workers’ compensation claims may be denied. 

Failure to Report Injuries Promptly 

At Belsky & Horowitz, LLC, our clients see denials for a variety of reasons, but one of the primary reasons is the failure to report injuries promptly. Most states have strict deadlines for reporting workplace injuries, typically 30 to 90 days after the incident.  

Failing to report within this timeframe can raise doubts about the legitimacy of the claim. Employers and employees should be diligent in reporting injuries as soon as they occur to avoid potential denial. 

The Maryland Worker’s Compensation Commission has specific reporting requirements for employers as well, stating:  

“If an accident occurs to an employee that results in disability for a period of more than 3 days, it shall be the responsibility of the employer to report this accident to the Workers ‘ Compensation Commission on a ‘First Report of Injury ‘ form within 10 days after notice of such accident, whether oral or written. Copies of this report must also be sent to your insurance carrier.” 

Lack of Medical Evidence 

Another common reason for denial is a lack of sufficient medical evidence to support the claim.  

Medical documentation plays a critical role in the workers’ compensation process, as it validates the extent of the injury and its relation to the workplace. Without comprehensive medical records, insurers may question the legitimacy of the claim, leading to denial.  

Employees should ensure they seek medical attention promptly and provide thorough documentation to support their case. 

Pre-Existing Conditions 

Pre-existing conditions (injuries or illnesses that predate a workplace accident) can complicate workers’ compensation claims and may result in denial if not handled properly. Insurers often scrutinize claims involving pre-existing conditions to determine whether the workplace injury simply exacerbated an existing medical issue.  

If the insurer believes the injury is primarily due to a pre-existing condition rather than a workplace accident, they may deny the claim.  

However, it’s important to note that aggravation of pre-existing conditions is often covered under workers’ compensation, provided it can be linked to the workplace incident. 

Disputes Over Causation 

Disputes over the cause of the injury are another common reason for claim denial. Insurers may argue that the injury was not directly caused by the workplace environment or job-related activities, making it ineligible for compensation.  

Maryland statutes dictate that worker’s compensation only covers “accidental personal injury arising out of and in the course of employment.”  

Proving causation can be challenging, especially in cases where injuries develop over time due to repetitive tasks or exposure to hazards. Both employers and employees should document workplace conditions and activities to establish a clear link between the injury and work duties. 

Violation of Company Policies 

Of course, claims can also be denied if the injury occurred while the employee violated company policies or engaged in misconduct.  

For instance, if an employee was under the influence of drugs or alcohol at the time of the injury, their claim may be denied. Similarly, injuries sustained during horseplay or other activities unrelated to their work may not be covered under workers’ compensation.  

Employers should enforce safety policies consistently to mitigate the risk of injuries and potential claim denials. 

Missed Deadlines for Filing Claims 

In addition to reporting deadlines, there are often specific time limits for filing workers’ compensation claims. Failure to file within the designated timeframe can result in automatic denial, regardless of the validity of the claim.  

Employees should familiarize themselves with the deadlines outlined by their state’s workers’ compensation commission or board and ensure all required paperwork is submitted promptly. Employers can also play a role in facilitating the claims process by providing necessary documentation and support. 

Independent Medical Examination Results 

In some cases, insurers may require injured employees to undergo an independent medical examination (IME) to assess their condition and eligibility for benefits.  

If the IME results differ significantly from the findings of the employee’s treating physician, it can lead to claim denial. Insurers may use IME reports to dispute the severity of the injury or its relation to the workplace, casting doubt on the validity of the claim.  

Employees should approach IMEs cautiously and seek legal guidance if they believe the examination is unfair or biased. 

Exemptions from Worker’s Compensation 

There are also some categories of workers which simply aren’t covered by worker’s compensation, including: 

  • Domestic servants (maids, nannies, or other household employees)
  • Railroad workers (railroads have their own program for injured workers)
  • Federal employees
  • Agricultural workers
  • Independent contractors and consultants (these are not considered employee positions from a legal standpoint)
  • Temporary, casual, and seasonal workers

Navigating the workers’ compensation system can be complex and claim denials can worsen an already stressful situation for injured employees. By understanding the common reasons for denial and taking proactive steps to address potential issues, both employers and workers can improve their chances of a successful outcome.  

Prompt reporting, thorough documentation, adherence to company policies, and seeking legal guidance when needed are crucial elements in overcoming obstacles and obtaining the benefits to which injured workers are entitled.  

With diligence and attention to detail, workers’ compensation claims can be effectively managed, providing support and protection for employees in their time of need. 





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