Denied Workers Compensation Claims

Unfortunately, even if your workers’ comp claim was justified, it may be denied. If you filed a workers’ comp claim to collect benefits after an on-the-job injury, but then found out that your claim was partially or totally denied, you have the legal right to contest or appeal this denial before a hearings officer. A workers’ compensation lawyer can help you mount an appeal and  may get you the benefits to which you are entitled.

Why Are Workers Compensation Claims Denied

A workers’ compensation claim may seem relatively straightforward. Indeed, workers’ compensation was designed to help people who were injured at their workplaces or on-the-job. Workers’ compensation insurance is an essential safety net that prevents injured employees and their families from struggling to pay their bills while a worker is recovering from an illness or injury. Unfortunately, legitimate claims are sometimes rejected. There are many reasons why a workers’ compensation claim might be denied, but all workers have a right to appeal should they feel the decision is incorrect. If you have had your claim denied, you have the right to appeal the decision. A workers’ comp attorney can help you with documenting your request and appealing unfavorable decisions.

Many reasons exist that contribute to why your workers’ comp claim may be denied, including the following:

  • You filed the claim incorrectly
  • Too much time went by before you filed
  • You failed to report your injury to your employer promptly
  • Workers’ compensation insurance does not cover that specific injury
  • Your injury does not match up with medical records

Work Injuries that Don’t Qualify for Workers Compensation

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Having a workers’ comp claim denied is not the same as having an injury that is not eligible for benefits. Workers’ compensation may not cover specific injuries. While it does cover most workplace injuries, some accidents do not qualify for this coverage. This includes injuries that are intentionally self-inflicted and injuries that were the result of any action that violates the employer’s company policy, such as being under the influence of illicit drugs or alcohol.

For instance, a worker cannot start a fight with a coworker and then expect to collect compensation for his or her injuries sustained in the altercation. This and similar actions constitute self-inflicted harm. Additionally, you cannot receive workers’ compensation benefits if your injury happened while you were breaking company policy. Even if the act was not a crime, it is still not eligible for coverage under workers’ compensation insurance.

Furthermore, if your employer discovers that you were injured while committing a crime at work, you will not have the right to collect workers’ compensation benefits. Any illegal activities are not connected with your job duties, so are excluded from benefits.

Appealing a Denied Workers Compensation Claim

Insurance companies send out determination letters throughout the course of workers’ compensation claims. If you wish to challenge the outcome, each determination letter is a separate determination and must be appealed individually. Therefore, your workers’ comp claim could potentially involve numerous appeals and hearings. However, all the determination letters and hearings are connected. Failing to appeal even a single determination letter at the beginning of your claim might impact all subsequent determination letters, and impair your ability to file an appeal. If at any point throughout the workers’ comp claims process, you receive a determination letter that you do not agree with, you have the right to appeal. However, you only a limited length of time to do this. This is why having a workers’ compensation lawyer on your side is so valuable.