The Top 5 Reasons Why Workers’ Compensation Claims Are Denied

Workers’ compensation protects workers from the financial burden of a job-related injury or illness. It provides crucial benefits to workers and their families when an accident or other dangerous conditions connected to their jobs harms them. Virtually all Kentucky employers must purchase workers’ compensation insurance for their employees.

Unfortunately, suffering a covered work-related injury or illness does not always guarantee that workers will receive workers’ comp benefits. Workers’ compensation insurers frequently deny claims. Here are the top 5 reasons workers’ compensation claims are denied and how the experienced Louisville workers’ compensation lawyers at Sam Aguiar Injury Lawyers can fight to get workers their benefits after a claim denial.

Why Do Workers’ Compensation Claims Get Denied?

There are many reasons why an insurance company might deny claims submitted by injured or sick Louisville workers. The following five reasons are the most common.

1. Failure to Report Injury or Illness in a Timely Manner

Louisville workers must report work-related injuries to their employers as soon as possible. They must also report an occupational disease as soon as they experience their first symptoms. Reporting an injury or illness triggers the employer’s obligation to notify the workers’ compensation insurance company of the worker’s condition, which is the first step toward obtaining workers’ comp benefits.

Any unnecessary delay in reporting an injury or illness to an employer can result in a denial of the worker’s claim. Louisville workers who get hurt or sick on the job should immediately alert their supervisor, regardless of how their injury or health condition happened, who was to blame for it, and even if they’re not 100% certain their job activities or working conditions caused it.

Workers should not worry about the consequences of notifying their employers. It is illegal for Louisville employers to retaliate against employees who get hurt or sick on the job or report their work-related health conditions. If this should happen, a personal injury lawyer with experience in workers’ comp cases can pursue justice and damages for the affected worker. 

2. Lack of Medical Evidence to Support the Claim

Workers’ compensation pays for medical care that is deemed reasonable and necessary to treat work-related injuries or illnesses. Before they will pay on a claim, however, insurance companies need proof of the workers’ medical condition. This might include records of emergency room treatment, hospitalization, physical therapy, and information on medication prescriptions that were used to treat the workers’ illness or injury.

Workers’ comp insurance companies often fault workers and their medical providers for not providing enough information to explain why a specific treatment is necessary. Workers should save all documentation they receive from a doctor and show it to a lawyer. Workers’ comp lawyers can work with medical providers to ensure that records contain explanations for the necessity of treatments.

3. Pre-Existing Condition or Injury

Workers’ compensation does not cover treatment of pre-existing health problems, meaning any injuries or illnesses incurred outside of work. However, it covers the workers’ costs and losses when job activities or workplace conditions worsen their pre-existing conditions. This distinction can be a fine line to draw, and it often leads to insurers denying valid workers’ comp claims.

Workers’ compensation insurance companies frequently ask workers to disclose all of their medical records for the insurer to review. Before agreeing, workers should consult with an experienced workers’ compensation lawyer in Louisville. Insurers ask to see a worker’s entire medical history because they want to find evidence of a pre-existing condition so they can justify a claim denial. To minimize the risk of this happening, a lawyer can often limit the scope of what the insurer gets to review.

4. Misconduct or Violation of Company Policy

Workers’ compensation is a form of no-fault insurance. It covers a worker’s injury or illness regardless of how it happened or who was to blame, with one significant exception. It does not cover injuries or diseases resulting from a worker’s misconduct or violation of a company policy. For example, a worker would be denied coverage for injuries suffered during a fistfight with a co-worker or due to being drunk or high on the job.

Insurers will often cite worker misbehavior as justification for a claim denial. To minimize the risk of that kind of accusation, workers should report injuries and illnesses promptly and be transparent about the cause. If they still face accusations from the insurer that they violated workplace policy, the worker should contact a lawyer who can develop a case demonstrating that they still deserve coverage.

5. Dispute Over the Cause of the Injury

Sometimes workers’ compensation insurance companies deny a claim because of a factual dispute about whether a work-related incident or condition caused the worker’s injury or disease. For instance, the insurer may think the worker suffered a back injury while doing chores at home or that a specific illness like asbestos is or lead poisoning cannot be linked to known conditions at a workplace.

Proving the connection between an injury or illness and a workplace may require a thorough examination of the worker’s job activities and environment. Sometimes insurers ignore or fail to recognize a cause that’s common knowledge to workers. A Louisville worker whose claim gets denied due to a dispute over its connection to their job activities or conditions should immediately contact a workers’ compensation lawyer for help collecting evidence and proving their claim.

Contact an Experienced Louisville Workers’ Compensation Lawyer

Workers’ compensation should pay for your medical care and lost income if you suffered an injury or illness due to your job duties or work environment. If a workers’ comp insurance company denies your claim, contact the workers’ compensation lawyers, Louisville residents trustat the offices of Sam Aguiar Injury Lawyers and get scheduled for a free case assessment.