5 Common Reasons Workers' Compensations Claims Are Denied

5 Common Reasons Workers’ Compensations Claims Are Denied

Workers’ compensation is a system that is set up to protect workers who sustain an injury or illness that is related to their job. In West Virginia, nearly all employers are required to maintain workers’ comp coverage for their employees. There are some exceptions; such as casual employers with fewer than three employees, agricultural employers with five or fewer workers, churches, employers of domestic services, and a few others.

Workers’ compensation is a no-fault system, which means that qualified employees are supposed to receive benefits through their employer’s policy no matter who was at fault for the injury.  This is supposed to benefit both employees and employers, because in exchange for no-fault compensation, employees are usually unable to file a personal injury lawsuit against their employer.

Workers’ compensation is supposed to provide access to the benefits an injured worker needs without having to go to the trouble of proving negligence against their employer. In theory, this should make it much easier for workers to access these benefits. In practice, unfortunately, it usually does not work out this way.

The employer’s workers’ compensation insurance company makes the initial determination on whether or not a work-related injury is approved or denied. The claims process is unnecessarily complicated and confusing, and insurance companies frequently deny workers’ claims. Sometimes, they might deny a claim for a valid reason, but oftentimes, there is no good reason for the denial at all.

Insurance companies can save untold amounts of money each year by denying workers’ compensation claims, and when they do this, their hope is that the injured worker will just take their word for it that the denial is valid and move on with their lives. And many frustrated workers do just that.

If you have been denied workers’ comp benefits, this is not necessarily the final word. Before you accept what the insurance company is saying, speak with a skilled and knowledgeable workers’ compensation lawyer about your claim. We may be able to help you appeal your claim and get you the benefits you deserve.

Common Reasons for Workers’ Compensation Claim Denials

There are several reasons a workers’ comp claim may be denied, here are five of the most common:

  1. The Injury Did Not Happen at Work

In order to receive workers’ compensation benefits, your injury or illness must result from the duties you perform during the course of your employment. So, one reason a workers’ comp claim is often denied is because the injury did not happen at work, or at least that is what your employer says. There can be a lot of gray area with this type of issue, however. 

For example, let’s say you were clocked out for lunch and your boss gives you money and asks you to go pick up food for you and the rest of your coworkers. While on the way to the restaurant, you are injured in a motor vehicle accident. In this case, benefits might get denied by the insurer because you were “off the clock” at the time of the injury. However, even though you were clocked out, you were still performing work related duties, because you were instructed by your boss to make this trip.

  • The Injury or Illness Resulted from a Preexisting Condition

There might be a question about the origin of your illness or injury. For example, you may say that you suffered a herniated disc in your back after lifting a 100-pound box at work. But the insurance company might say that you already had a back injury before you picked up that box, because you had been going to the chiropractor before that regularly for maintenance adjustments. This is another one of these gray areas where the insurance company may very well come down on the side of denying the claim, even though you may have sufficient medical evidence to show that lifting the box at work caused the herniated disc.

  • The Injury was Not Reported in a Timely Manner

Every state has certain deadlines for reporting a work-related injury. In West Virginia, you are supposed to report your injury to your employer as soon as possible. But as with many other workers’ comp-related issues, things are not always this simple. For example, many injuries occur over an extended period of time; such as repetitive stress injuries and occupational illnesses. For this reason, it may take time for you to discover these injuries and take appropriate actions. But again, insurance companies will be more than happy to deny a claim if they can find a reason to say that you did not report your injury in a timely manner.

  • You Failed to Seek Immediate Medical Treatment for the Injury

Along the same lines as the previous point, maybe you felt pain in your lower back after picking up that 100-pound box, but you decided to try to tough it out – hoping the pain would eventually go away.  But after a few days, you realized that something was seriously wrong, and you needed to get medical help.  In this type of situation, an insurance company might claim that you were faking the injury or that it was not as serious as you said it was because you did not get treated for it right away. They might also question the origin of the injury because you waited so long to get treated, or they might say that you did not do enough to mitigate the extent of your injuries.

  • You Were Intoxicated at the Time of the Injury

Employers have a few legitimate reasons for denying workers’ comp benefits for a work-related injury. One of these is if you were injured while under the influence of alcohol or drugs. That said, employers in West Virginia are not allowed to test employees arbitrarily for drugs and alcohol after every work-related accident. Under OSHA guidelines, an employer is only allowed to perform such tests when there is “a reasonable possibility that drug use by the reporting employee was a contributing factor to the reported injury or illness.”

Speak with an Experienced Workers’ Compensation Attorney in West Virginia

If you or a loved one has been denied workers’ comp benefits, this is not the time to give up.  Many denials are not legitimate, and it might be possible to successfully appeal your claim.  The appeals process is complex and challenging, however, and you need strong legal counsel by your side to increase your chances of a favorable outcome.

At Bailey, Javins, and Carter L.C., we have stood up for injured workers in West Virginia for almost 50 years. We have successfully taken on giants in some of the most dominant industries in our state, and we have the experience, skills, resources, and dedication to help ensure that our clients are fully and fairly compensated for their injuries.  

Call our office today at (800) 497-0234 or (800) 296-6979 or message us online to schedule a free consultation with a member of our legal team.