How often are workers’ compensation claims denied? Too many workers’ compensation claims in Illinois are denied on the first go-around. A good number do get accepted on appeal, especially when workers have professional help navigating the system. Denial can result from even a seemingly small matter, such as when exactly you filed the claim.
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Common Reasons Workers’ Compensation Claims Are Denied
The workers’ compensation system is tricky for claimants to navigate by themselves. It is not user-friendly. Filing claims involves a lot of organization, paperwork, deadlines, and know-how. These items by themselves can be overwhelming but are especially burdensome to recovering victims.
The presence of illegal drugs in workers’ systems impacts how often workers’ compensation claims are denied. Workers’ compensation laws do not cover injuries or illnesses caused by alcohol or drugs. If emergency room documents after your work accident show you had illegal drugs in your body, expect your claim to be turned down.
In addition to drug use, employers may deny claims for the following reasons:
Conflict About Whether Your Injury Is Related to Work
The fact that your injury is work-related may seem clear-cut to you, but insurance companies have a high standard of proof. Disputes over how an injury occurred are common. For example, your employer might claim:
- You were involved in unsanctioned work conduct (misconduct) when the injury happened.
- You were not working when you got hurt.
- Your injuries or medical condition simply did not result from any type of exposure at work or a workplace accident.
You can still get your claim approved despite what your employer says, but you need evidence for that to happen. For one thing, doctors, including independent medical professionals, may be able to attest to the fact that your injury is work-related. Similarly, there may be witnesses to the injury who can explain that it happened at work.
When unwitnessed injuries occur, it is even more critical for you to report the injury right away and through the proper channels. Tell supervisors, colleagues, and co-workers about the injury too.
You Submitted the Claim After Leaving the Job
Workers’ compensation insurers deny many claims filed after someone leaves their job (whether through voluntary quitting, a layoff, or a firing). Insurance companies are rarely inclined to accept claims at face value. If you file after being fired, the insurers think you are seeking workers’ compensation out of revenge.
If you can show good reasons for not filing until after you left the job, you improve your chances of having a claim accepted. One scenario is when you are injured after you already gave notice you were leaving. Maybe you were even hurt on your very last day on the job.
Some employers fire employees for reporting workplace injuries. This type of behavior is illegal. If you were not expecting to be fired, and it happens quickly, that is a logical reason as to why you would not have filed until after you left the job. A workers’ compensation lawyer in Illinois can explain the state’s rules for workers’ compensation claims filed post-employment and whether you qualify for an exception.
Your Condition Falls Outside of State Guidelines
States have different laws restricting what is allowed in workers’ compensation claims. Many injuries are not deemed severe enough, but some are. For instance, some states allow claims stemming from the long-term psychological stress people suffer in some jobs.
You Missed Important Workers’ Compensation Deadlines
Missed deadlines contribute to how often workers’ compensation claims are denied. The first deadline is that you must report your injury or illness within 45 days to your employer. Your employer should have notices and materials about when, where, and how to report, and to whom. Your supervisor should also ensure you get appropriate medical attention.
The next step is to file a claim with the state. In some states, the insurance company or employer handles this step instead.
- Insurers tend to assume that someone who does not immediately report an accident is not really hurt.
- Report your injury as soon as possible, sooner than 45 days, especially if you may have to miss work for it. Even if you believe there is less than a 1% chance of you not being able to go to work, report what happened and fill out the accident paperwork. You want your benefits to be available promptly should you need them.
Each state has its own timeframe for reporting injuries and filing claims. Miss any of these deadlines, and your claim is likely to be denied. The states generally require written notice when you inform employers about your injury. In some states, you might not be penalized for slipping up on the written notice part as long as one of your direct supervisors knew you had a work-related injury.
Perceived Lack of Cooperation With Insurance Company
Attorneys can be tremendous assets when it comes to communicating with insurers. Insurers typically ask employees to provide recorded statements explaining the accident and the injuries they suffered. Employees may not want to do so for any number of sensible reasons, but might not realize that insurance adjusters could deny a claim because an employee would not give a statement.
In the same vein, insurance adjusters want to see complete medical records rather than those that have been scraped together or cherry-picked. If employees don’t sign medical authorizations giving insurers permission to get all types of medical records and bills, that could doom a claim.
There are many legitimate reasons for not signing this type of authorization. For example, you may not want the insurer to see all of your records when you are required only to submit those related to the claim. You may prefer to get the appropriate records on your own and submit them.
What to Do If Your Workers’ Compensation Claim Is Denied
If your claim is denied, carefully review your claim denial letter. It should contain the reasons behind the denial. Insurers can deny your claim for any number of reasons, not all of which are listed above. For example, reasons for TDIU denial (total disability individual unemployability denial) may relate to the inclusion of incorrect information and inappropriate determinations about what kind of work applicants can do.
If the matter is relatively simple, such as a missing piece of documentation you did submit, you can risk getting in touch with the insurance adjuster to explain that the paperwork is there.
Even with these simple cases, though, you are usually better off contacting a lawyer. Even if you eventually decide to appeal the claim yourself, lawyers can help you understand what to do if workers’ comp is denied.
Appealing a Workers’ Compensation Claim Denial
The answer to, “how often are workers’ compensation claims denied?” is that insurers deny them too often. The appeals process can be lengthy and requires patience. Attorneys can help you avoid common mistakes, such as missing deadlines and speaking indiscreetly about your case.
