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Understanding workers’ compensation claim denials

Workers’ compensation is designed to provide financial protection to employees who suffer injuries or illnesses. However, not all claims are approved.

Understanding why claims may be denied can help employees navigate the process of pursuing benefits more effectively.

Failure to report immediately

Prompt reporting of workplace injuries or illnesses is necessary for a successful workers’ comp claim. If an employee delays reporting their injury or illness, their claim may be denied and the insurer may question its validity or the severity of the condition.

Lack of sufficient evidence

Insufficient evidence to support the claim is a common reason for denial. This may include incomplete medical records, conflicting witness statements or a lack of documentation regarding the incident. Without adequate evidence, an insurance company may question the claim’s legitimacy.

Pre-existing conditions

Pre-existing conditions can complicate claims. A work-related injury may aggravate these conditions, and the insurance company may deny the claim, insisting that it is not work-related “enough” to be a covered concern. Determining whether the injury is directly related to the job or exacerbates an existing condition can be challenging.

Violation of company policies

Claims may be denied if an injury occurred while an employee was violating company policies or engaging in prohibited activities. This could include drug or alcohol use, horseplay or failure to use safety equipment as required.

Missed deadlines

Failing to meet deadlines for submitting paperwork or attending medical appointments can result in claim denials. Timely submission of all required documentation is essential for any workers’ compensation claim.

The process to file a workers’ compensation claim is challenging. Also, claims may be denied for various reasons. By understanding these common reasons for denial and taking proactive steps to address them, employees can increase their chances of a successful outcome when filing a workers’ compensation claim.


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