Common Reasons Workers’ Compensation Claims Are Denied

Workers who file a workers’ compensation claim expect their injury or illness to be fully covered by their employer’s insurer. Unfortunately, there are legitimate instances when an insurance company can deny a claim. Here’s how to reduce the risk of your claim being denied.

1. Missed deadline

Taking too long to file the necessary paperwork with your employer can mean missing the reporting deadline, which is used by insurers to weed out fraudulent claims. For this reason, workers need to inform their employer as soon as possible after sustaining a work-related injury or illness. In some cases, it may be necessary to hire a workers’ compensation attorney in Orange County to help file your claim and obtain the benefits you deserve.

2. The illness or injury wasn’t work-related

A workers’ compensation insurance company can claim the injury wasn’t work related if:

• There weren’t any witnesses when the injury occurred
• The injury was caused by a hobby or recreational activity, even if it occurred in the workplace
• The illness or injury was caused by a pre-existing condition
• The injury occurred while the employee was on their way to work or going home, or during a break
• The worker didn’t notify the employer when the injury occurred

3. The illness or injury was due to horseplay

If the employee was engaging in horseplay, roughhousing, or joking when the injury occurred, the claim may be denied. The injury may be classified intentional if the employee broke safety protocols by engaging in reckless behavior.

4. The employee was intoxicated or under the influence of illegal drugs

Workers who are injured while drunk or high on drugs do not qualify for workers’ compensation benefits. In these cases, workers may be terminated if a drug test shows they consumed alcohol or illegal substances while on the clock.

5. The employee skipped medical appointments

It’s important to seek medical attention for an injury or illness as soon as possible. If the worker delays treatment in the hopes that the injury or illness will heal on its own, but their condition worsens or doesn’t improve, filing a workers’ compensation claim will likely lead to a denial of benefits.

6. The employee accessed out-of-network medical care

When seeking medical care, employees need to check policy requirements and ensure they only see an in-network doctor. The employer should provide the worker with information about which doctors and facilities they can receive treatment from.