7 common reasons why workers’ compensation claims get denied

Workers’ compensation insurance covers employees in the event of an injury that occurs in the workplace. This coverage provides medical care, wage compensation and recovery support to ill and injured employees, provided their condition occurred during work hours and as a result of workplace operations.

Though these benefits do much to help affected employees with injury and illness recovery, worker’s compensation claims are not always approved.

Workers’ compensation claim denials

Claim approval depends largely on the circumstances of the injury and various factors both inside and outside of the employee’s control. These factors include:

1. Insurance coverage, as some injuries or conditions are ineligible
2. Timeline delays if paperwork is not promptly submitted or processed
3. A weak or unsubstantiated report, particularly with no solid documentation or witnesses
4. Pre-existing conditions, including further trauma to an existing injury
5. Intentional or ineligible injuries, typically as a result of neglect or horseplay
6. Substance abuse at the time of the injury as evidenced by a drug test
7. Injury fault, including workplace fights or willful employee actions

Claims may also see denial if an employee, employer or insurance company fails to cooperate or participate in important claim processing steps.

Employees’ next steps

Denied claims are not an automatic dead end. Employees may appeal a denial decision if they feel it was unjustly rejected. If a claim is entirely denied, or if benefits are inadequate, employees can file an appeal or objection to the decision and may request a hearing to find a new settlement.

A strong worker’s compensation appeal case, one with sufficient evidence and prompt submission, can provide employees with the necessary benefits and compensation to recover and rehabilitate an injury and return to work as healthy and secure as possible.