In the realm of workers’ compensation, it’s crucial to emphasize the no-fault nature of the system. Coverage is generally provided regardless of whether an injury results from an honest mistake. 

However, the insurance company may deny a claim if they can demonstrate that the injury or illness occurred due to neglect, workers comp laws violations, or disregarding workplace safety protocols. While the system is designed to provide coverage without assigning blame, certain behaviors or actions that breach safety standards may be grounds for denial.

  • You Didn’t Tell Your Employer About Your Injury

Failing to inform your employer about your injury can impact your worker compensation eligibility. The specific timeframe for reporting workplace incidents varies by state, with some allowing a 30-day window and others requiring notification within a few days. 

You are responsible for being aware of the reporting deadline and ensuring timely communication of the injury to your employer to maintain eligibility for workers’ comp benefits. (Get more information on Does Surgery Increase Workers’ Comp Settlement?)

  • You Didn’t File a Claim In Time

Once you’ve informed your employer about your injury or illness, it’s crucial to ensure that a workers’ comp insurance claim is filed within the specified timeframe. While in many states, employers handle the filing process, you might have the option to initiate the claim yourself. 

Regardless of the approach, staying proactive is essential. The timeframe for filing varies by state; most provide at least one year, but some, like Nevada, require submission within a stricter 90-day window. Filing within the designated period is paramount to retaining access to workers’ comp benefits. (Learn more on When Will Workers’ Comp Offer A Settlement?)

  • You Never Stopped Working

Workers’ compensation benefits are designed to support individuals who need to miss work due to injury or illness. If you continue working without taking time off, benefits may not be accessible. Each state has its waiting period, typically ranging from three to seven days before workers’ comp benefits commence. 

If your treating physician approves you for light-duty work, deviating from this recommendation by returning to your regular job or taking on excessive work in other roles could lead to a denial of your claim or termination of benefits by the insurance company. Adhering to medical guidance is crucial for maintaining workers’ comp benefits eligibility.

  • Your Injury Or Illness Didn’t Happen On The Job

A crucial factor in a workers’ comp claim is establishing that your injury occurred while performing job-related duties, even if it happened outside the workplace. While commuting to the office before work isn’t covered, activities like offsite meetings with clients fall under the scope of coverage. 

This distinction is significant, as any suspicion from your employer or their insurance company regarding your engagement in work duties may lead to claim denial. It’s advisable to meticulously document the circumstances of the injury to eliminate doubts about its work-related nature. Prompt documentation ensures a fresher memory of the details, bolstering the validity of your claim.

  • Your Claim Is For a Pre-Existing Medical Condition

Workers’ compensation benefits are applicable if a workplace incident exacerbates a pre-existing illness or injury or stems from repetitive use motions. (Learn more on how to file a worker’s comp claim)

For instance, if you have pre-existing back pain and exacerbate it while unloading heavy boxes, you can likely qualify for benefits. However, the insurance company may use your pre-existing condition as a basis for denial, arguing that you’re filing a claim for an existing condition. 

To overcome this, you must convincingly demonstrate that your workplace activities worsened the pre-existing condition. Seeking the assistance of a workers’ comp lawyer can be beneficial, as they have the expertise to challenge the insurance company, providing evidence to substantiate your claim for deserved benefits.

  • You Received Out-Of-Network Medical Care

Your employer’s insurance company typically directs you to receive medical care from an approved doctor, a measure to maintain control and ensure perceived impartiality in the treatment process. 

Some states, such as Georgia, mandate the use of in-network doctors, where employers meeting specific criteria establish a “Panel of Physicians” for employees. Similarly, California requires adherence to the employer’s Medical Provider Network (MPN) unless a personal doctor is predesignated for workplace injuries. 

Seeking care outside these networks may lead to the insurance challenging or denying your claim, emphasizing the importance of compliance with state-specific regulations for coverage eligibility.

  • Workers’ Compensation Doesn’t Cover Your Job

Workers’ compensation insurance coverage varies, and not all types of employees are included. Typically, full-time and part-time employees, where taxes are withheld from paychecks, are covered. Conversely, individuals in roles such as independent contractors, freelancers, consultants, gig workers (Uber, Grubhub, DoorDash drivers), volunteers, and temporary workers are often not covered and may face claim denials. 

However, exceptions exist in certain states; for instance, in California, seasonal workers may qualify for coverage under their employer’s insurance. Volunteer firefighters in New York also receive workers’ comp coverage. Instances of misclassification as a consultant or independent contractor can be addressed with the assistance of a workers’ comp attorney, especially if you believe you should be classified as an employee under your state’s rules. An experienced law firm can help navigate the appeals process in the event of a claim denial.

Disability Claim Denied? Get Legal Help From An Attorney

Many workers’ compensation claims face initial denials, but it’s important not to lose hope. A workers’ comp lawyer, familiar with local regulations, can assist in appealing for essential medical care and compensation.

This ensures that individuals seeking legal assistance for their workers’ comp claims do not face financial burdens during the claim process.