Why Was My Workers’ Comp Claim Denied?

Workers’ compensation claims are designed to provide financial support and medical care for employees who are injured on the job. However, not all claims are accepted. Many employers and their insurance companies look for ways to get out of paying injured workers the benefits they are entitled to. If your claim was denied, call an Arlington Heights, IL workers’ compensation lawyer from Therman Law Offices, LTD to find out how we can help.

Failure To Report The Injury Promptly

One of the most common reasons for workers’ compensation claim denial is failure to report the injury in a timely manner. In Illinois, you must report your injury within 45 days of the incident. If the injury is not reported promptly, the employer or the insurance company may argue that the injury was not work-related or that it occurred after the employee had left work. Delayed reporting can create doubts about the legitimacy of the claim and may result in a denial.

Injury Not Work-Related

For a workers’ compensation claim to be approved, the injury must be work-related. If there is any question about whether the injury occurred during the course of employment or while performing work-related duties, the claim may be denied. For example, if an employee sustains an injury while engaging in activities unrelated to their work (such as a personal errand or during a break), the claim might be rejected. The employer may argue that the injury was not caused by a workplace incident but rather by personal activities or pre-existing conditions.

Pre-Existing Conditions

If an employee has a pre-existing medical condition that may have contributed to their injury, the claim may be denied or reduced. Employers and insurance companies may argue that the injury was exacerbated by the worker’s pre-existing condition rather than caused by the work environment. For example, if an employee with a history of back problems sustains a back injury at work, the insurance company may dispute that the work environment or tasks caused the injury. However, in some cases, workers may still be eligible for compensation if the work aggravated the pre-existing condition.

Lack Of Medical Evidence

Workers’ compensation claims rely heavily on medical evidence to prove that an injury was sustained at work and that it requires treatment. If a worker fails to provide sufficient medical documentation or if the medical reports do not support the severity of the injury, the claim may be denied. It is crucial for employees to seek medical attention immediately after an injury and to follow through with all recommended treatments. A lack of clear medical evidence linking the injury to the workplace can be a significant obstacle to a successful claim.

Employer Disputes The Claim

In some cases, the employer may dispute the validity of the claim. Employers may argue that the injury did not occur at work, that the employee was not performing work duties at the time, or that the injury was caused by the worker’s own negligence. Employers may also argue that the injury was self-inflicted or the result of misconduct, such as being under the influence of alcohol or drugs while on the job. If the employer disputes the claim, it can complicate the approval process, leading to a denial or delay in compensation.

Failure To Follow Proper Procedures

Workers’ compensation claims have specific procedural requirements that must be followed. For example, the employee may need to fill out specific forms, provide detailed descriptions of the injury, and cooperate with medical evaluations. If any of these steps are overlooked or incorrectly completed, the claim can be delayed or denied. It’s essential for employees to follow the correct process, including notifying the employer and filing the necessary paperwork within the required time limits.

Injury Occurred During Misconduct Or Illegal Activity

If an employee is injured while engaging in misconduct or illegal activities, such as being intoxicated at work or violating safety rules, their workers’ compensation claim may be denied. Workers’ compensation does not cover injuries that result from actions outside the scope of employment, such as horseplay or fighting with coworkers. Injuries resulting from these types of activities are typically excluded from coverage.

Employee Fails To Cooperate With The Insurance Company

Workers’ compensation insurers may require the injured worker to cooperate in certain aspects of the claims process, such as attending independent medical examinations (IMEs) or responding to requests for additional documentation. Failure to cooperate with the insurer or to follow through with their requests can result in a denial of the claim. It is essential for employees to be responsive and engaged in the process to avoid any issues with their claims.

Call Our Law Firm For Help

Understanding the reasons why a workers’ compensation claim can be denied is critical for employees who want to protect their rights and ensure they receive the benefits they deserve. If a claim is denied, it is important to seek legal advice to explore options for appealing the decision or pursuing alternative legal actions. Call Therman Law Offices, LTD for a free consultation to learn more.