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Why do workers’ compensation insurers deny claims?

On Behalf of | Feb 6, 2024 | Workers' Compensation, Workers' Compensation Process |

In an ideal setting, workers’ compensation should pay for any and all claims for work-related injuries and illnesses without question. When a worker’s health is on the line, the last thing they should worry about is whether they can afford medical treatment.

However, workers’ comp claims must go through the employer’s insurer first for approval. While most insurers are sensible, they can still turn down a claim for various reasons.

This blog will list down some of the common grounds for claims denial.

Incomplete or late filings

In California, workers must report their injury to their employer within 30 days. Once the employee reports their injury, their employer must give them a claim form at once, which the employee must also accomplish as soon as possible. Mistakes in paperwork or missed deadlines can lead to claim rejections.

Disputes over work-related injuries

Insurers often deny claims if there is a question about whether the injury is work-related. If an employee suffers an injury during a break or while commuting, the insurer may argue the injury isn’t eligible for coverage.

Employment status issues

Independent contractors (such as ride-sharing drivers) are generally not covered by workers’ comp. Insurers will check the employment status at the time of the injury and may deny claims if the worker is not considered an employee.

Lack of medical evidence

Medical evidence is crucial to support a claim. Insurers may deny the claim if there’s no adequate medical documentation correlating the injury to the workplace accident or conditions.

Pre-existing conditions

If an insurer can argue that a pre-existing condition caused the injury, they may deny the claim.

Inconsistencies in the claim

Discrepancies between the employee’s account of the incident, the medical records, and witness statements can lead to denials due to questions about the claim’s validity.

Understanding the common reasons for workers’ comp claim denials can help in effectively navigating the claims process. Remember that you have the right to appeal a denial. Consider seeking a legal professional who can guide you through the appeal process.