Reasons Workers Comp Claims are Denied
There are many reasons why workers’ comp claims are denied, ranging from preexisting conditions to going out-of-network, and lapses on the part of the employer or employee. Regardless of the reason, getting rejected can be a crushing blow for the person filing the claim. And if the incident necessitating the claim results in costly medical expenses and long-term loss of income, the consequences can be devastating.
How likely are workers’ compensation claims to be denied by an insurance provider? Estimates place the figure at around 25% or more. This means that as many as one out of four claims can be turned down off the bat.
Worse still, there is often no good reason for these denials. In some cases, insurers reject claimants automatically, hoping they will be discouraged from pursuing the claim further and just give up.
Of course, some of the reasons given to claimants will be valid. As disheartening as it may be to be turned away, there are cases wherein it might be because of lapses, negligence, or wrongdoing on the claimant’s part.
This is why it is so important to be aware of the common reasons why workers’ comp claims are denied. Knowing what to expect when filing a claim will help determine whether the decision is valid or not.
Reasons why workers’ compensation claims are denied
Getting medical care out-of-network
Most workers’ compensation policies have specific requirements regarding where and how claimants obtain medical care. Employees injured at work will usually have to get treatment from a doctor or medical facility specified in their employer’s policy. While some plans require the claimant to get only initial medical care from a designated specialist or hospital, others may limit them to in-network care for the duration of their treatment.
Claimants that get medical care out-of-network will almost always be denied compensation when they file a claim. This is why it is crucial to follow the policy requirements to the letter.
Presence of a preexisting medical condition
Claimants may be denied compensation if it is later found that they had a preexisting condition at the time of the incident necessitating the claim. In some cases, unscrupulous employers may insist that an injured claimant’s condition is due to a much earlier incident. Working with an attorney and documenting the incident will help ensure that claimants get the compensation they deserve for a work-related injury.
Insufficient documentation
Incomplete documents or late paperwork is one of the most common reasons claims are denied. Insurance firms tend to be pretty strict and unforgiving about failure to provide supporting documents and will reject a claim immediately if they are lacking or handed in past the required date.
Some companies will even deny a claim if only one document is missing or the requirements are late. These incidents can be avoided by having an experienced workers’ comp attorney handle the claim from the beginning to avoid missing crucial filing dates or important documents.
Intentional neglect or inappropriate behavior
Workers’ comp only applies to incidents resulting from unintentional actions or circumstances. If an employee gets hurt after showing off to a coworker or playing around when they should have been working, the insurer will probably not honor the claim.
That being said, it is important to distinguish between intentional action and liability. Although workers may be responsible for injuring themselves or their coworkers, they may still be eligible to receive compensation if the incident didn’t result from intentional neglect or disregard of safety protocols.
Legal issues and insurance company policies
Finally, there are cases wherein compensation claims may be denied due to legal issues and policies implemented by the company management. Claimants can miss legal loopholes and unfamiliar company regulations and may only become aware of these issues when an incident occurs that necessitates filing a claim.
Some companies may even become uncooperative and delay their response to a claim until just before the deadline for filing is due to elapse. Again, these problems can be avoided by consulting with a claims attorney.
Remember that being forewarned is being forearmed. Knowing these reasons and keeping them in mind before filing a claim could increase the chances of being granted compensation. When the time comes that a worker needs to be compensated for an injury or loss of income, knowing this information will hopefully help them to deal with the situation to their advantage.
About Daniels Insurance, Inc.
At Daniels Insurance, Inc., we have a unique understanding of the risks that businesses like yours face on a regular basis. With the backing of our comprehensive coverages and our dedication to customer service and quick claims resolution, your business will be fully protected. For more information, contact us today at (855) 565-7616.