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Reasons you received a workers’ compensation claim denial

On Behalf of | Mar 29, 2023 | Blog, Workers' Compensation |

In 2021, 2.2-2.6 million individuals received injuries or became ill on the job, and in 2020, more than 118,000 people filed workers’ compensation claims.

Although the average cost for these claims was over $41,000, not all workers’ compensation claims receive approval from the insurance company. These are some reasons for claim denials.

Some of the blame falls on the claimant

If a worker does not follow safety protocols, comes to work under the influence or acts in an unprofessional manner, an insurance company may find that the injury was in part the claimant’s fault. This includes joking or horsing around in the workplace. The company may deny a claim if the employee received an injury during a break or when he or she was not actively working as well.

The employer does not agree

An employer may outright deny an injury occurred, but in most cases, companies dispute the way, time or location of the incident. Claim paperwork needs to align exactly with any report made to the employer. In addition, the employer may have witnesses that dispute the information in the report.

Preexisting conditions or previous claims

If employees submitted previous claims for the same or a similar injury, even if they received a new injury in that area, they may receive a denial. In addition, if the employee had a preexisting condition and the injury is near, in the same area or otherwise connected, a denial may occur.

Inappropriate or no medical treatment

Most insurance companies require that claimants use authorized medical centers and providers. In addition, they tend to deny claims for individuals who did not seek medical attention.

Injured employees need strong foundations for their workers’ compensation claims, which require immediate reporting of any injury to their employers followed by submitting a claim before the deadline.