While only a mere 2% of workers compensation claims are ever found to be fraudulent, you might think the percentage was closer to 92% due to the way that some insurance companies often respond to claims.Insurance companies want to thoroughly investigate every claim, making it seem like every claim might be suspect, every worker intoxicated, and every employer negligent. Don’t let these hurdles to your workers’ compensation claim get in your way.
Here are 5 common reasons your workers comp claim could be denied and what to do next.
- Non-Compensable Injury
If you were denied compensation following your workers’ compensation claim, it could be because the company determined it was a “non-compensable” injury. Every state has a series of requirements that an injurymust meet in order for it to be covered. (Click here to access the State Board of Worker’s Comp for the state of Georgia.) If your injury fails to meet these requirements, you can still appeal, but you need to know why it might have been denied.
Insurance companies will sometimes use complicated language regarding a non-compensable injury, which can obfuscate the issue. It leaves the injured party feeling confused and overwhelmed, potentially allowing insurance companies to avoid paying what they should. Non-compensable injury is a vague and oft-confusing term that an injured worker unfamiliar with the laws in Georgia might not fully understand. If your claim was denied, comb through the types of injuries covered to make sure that you’re eligible. Check out Hollington Brown’s frequently asked questions regarding covered injuries for more information. And if you’re unsure, contact us and we’ll help you.
- The Injury Was Unexplained
When you’re injured, it’s simply not enough to say you were injured on the job. In order for the insurance company to determine whether or not your injury is eligible for workers’ compensation, they need to know thespecific details.
If the injury sustained was not related to the work you do or not “unique to the job,” the employer might not cover it (for example, if you tripped over your own shoelace while walking to the breakroom). However, if you fell because the floor mat at your job was improperly placed or because they didn’t provide you with an item needed in order to prevent the fall, they could be at fault. Whatever the case may be, you’ll want to provide as much detail regarding the injury as possible. Often, workplace injuries don’t suddenly happen; instead, they occur over long periods of time (for example, carpal tunnel syndrome). In cases such as this, you’ll want to look back at medical records and reference pertinent dates whenever possible in order to give a clear picture of the injury development.
If your workers’ compensation claim came back with a denial, see if you can provide additional testimony to support your claim.
- You Had a Pre-existing Injury
If you’ve followed the narrative of health care debates in recent years, you’ve likely heard the term “pre-existing condition.” It’s one of the common reasons claims are denied by insurance companies. They’re basically saying, “it’s someone else’s problem, not ours.” Don’t let an insurance company get away with this denial.
When a legitimate work compensation claim is denied because of a “pre-existing injury,” it’s important to contact an experience workers compensation firm like Hollington Brown so we can go to bat for you. If yourmedical issues have been exacerbated because of an on the job injury, it’s possible that treatment could be covered by workers’ comp.
- No Supporting Documentation
If you’ve been injured, insurance companies have the right to access your medical records in order to verify the legitimacy of your claim. They also have the right to check out any of the records related to the injury that you’re claiming.
If you fail to sign the release forms or refuse them this right, you could be denied based on their inability to see supporting documents.
It’s not uncommon for injured workers to send their documentation to insurance companies only for them to claim they never received them. In order to avoid this issue, it’s a good idea to send supporting documentation to both the insurance company and the State Board of Workers’ Compensation.
Once you do this, all the records you submit will be on file with the agency, meaning that the insurance company will have shared access to them. This allows you to have a second agency to support your claim that you submitted the material as well as to have your submission on legal record.
- Failure to Report Your Injury
If you didn’t report your injury correctly or if you didn’t do it on time, this could allow insurance companies time to delay paying you and, in some cases, simply discourage you from getting what you’re owed.
While you should report the claim as soon as possible, it’s difficult to think about calling an insurance company in the hours following an accident. Once you have an experienced legal team to back you up, you’ll often find that the insurance company is denying you for unlawful reasons.
A Workers’ Compensation Claim is Your Right
If you feel like your workers’ compensation claim is being denied for illegitimate reasons, you can still take legal action. Don’t be discouraged by a denial. This is your opportunity to make your claim airtight.
Once you’re able to make your claim properly, follow our guide to make sure your settlement is fair.