Why Your Workers' Compensation Claim Could Be Denied

Here are some of the most common reasons a workers' compensation insurer would question the validity of your work injury claim.

By , J.D. · University of San Francisco School of Law

Workers' compensation insurers deny many legitimate claims, forcing honest and innocent employees to hire a lawyer and navigate the workers' compensation system to secure their benefits.

The insurer is more likely to deny your claim if any of the following circumstances apply:

  • Your injury was unwitnessed.
  • You didn't report your injury immediately.
  • A discrepancy exists between your accident report and your initial medical records.
  • Your initial medical records indicate the presence of illegal drugs in your system.
  • You filed a workers' compensation claim after you were fired or laid off.
  • You refused to give the insurance company a recorded statement or refused to sign medical authorizations.

Your Injury Was Unwitnessed

Workers' compensation insurers never like unwitnessed injuries. They question the vast majority of unwitnessed accidents. If you get hurt at work and no one saw your accident, there is nothing you can do about that. But you should certainly make sure to report the injury to your coworkers and your supervisor immediately. And, you should make sure that you tell everyone the exact same thing about how your injury occurred.

You Didn't Report Your Injury Immediately

Workers' compensation insurers don't like cases where the accident doesn't get reported immediately either. They assume that, if you didn't report the accident immediately, you weren't really hurt.

Most states' workers' compensation laws require you to report work related injuries within a short time period, sometimes in as little as seven days. Don't wait even that long. If you get hurt at work, and you think that your injury has the slightest chance of causing you to miss any work, report it immediately to a supervisor and fill out an accident report. Doing so will increase your chances of getting benefits as soon as you need them.

A Discrepancy Exists Between Your Accident Report and Your Initial Medical Records

Insurers will often deny workers' compensation claim when the employee's statements about how the accident happened are inconsistent. If you tell your supervisor that the accident happened one way, but tell your doctor that the accident happened in a different way, that will hurt your case. Make sure that, when you tell coworkers, supervisors, people in the personnel office, and health care providers about how the accident happened, you are consistent down to the smallest detail.

Your Initial Medical Records Indicate the Presence of Illegal Drugs in Your System

Injuries caused by drug or alcohol use aren't covered by workers' compensation laws. If an employee goes to the emergency room after a work-related accident, and the emergency room records show illegal drugs in the employee's system, the insurer won't pay the ensuing workers' compensation claim.

You Filed a Claim After You Were Fired or Laid Off

Sometimes, employees who were legitimately injured at work delay filing a workers' compensation claim. Then, by the time they get around to filing the claim, they've been fired or laid off.

Insurers never trust workers' compensation claims that are filed after the employee gets fired or laid off. They almost always assume that the claim is nothing more than a revenge claim. This is another reason not to wait to file a claim if you have a legitimate work-related injury. If you get laid off before you file your claim, you are going to have a difficult time convincing the insurer and the workers' compensation judge that you really did have a work-related injury.

You Refused to Give the Insurance Company a Recorded Statement or Refused to Sign Medical Authorizations

Workers' compensation insurers will often ask injured employees to give a recorded statement describing the accident and the injuries. Unfortunately, that puts the employee in a difficult position. As a general rule, giving a statement will not help an injured employee who doesn't have a workers' comp lawyer. Nor is the employee legally required to give the insurer a recorded statement.

If the insurer asks for a statement, that is usually a sign that the insurer has a problem with the case. If the employee gives the statement, the insurer is still probably not going to award that employee workers' compensation benefits. But if the employee refuses to give the statement, then the adjuster has grounds for denying the claim.

Insurers will also generally ask the employee to sign medical authorizations that will allow the insurer to write directly to the employee's health care providers to get the employee's medical records and bills. Again, the employee generally has no legal obligation to sign medical authorizations. An injured employee who is filing a workers' compensation claim does have the obligation to give medical records and bills relating to the work accident to the insurer. The worker can meet that obligation by simply getting the records on his or her own and sending them to the insurer.

However, insurers don't like when employees provide their own records. They don't trust injured employees. Insurers like to get the medical records on their own. That way they can be sure that they get a complete file, not one that has been cherry-picked. The problem with medical authorizations is that sometimes the insurer will invade your privacy and get medical records that do not relate to the work accident.

If the insurer pushes you to sign a medical authorization and you would prefer not to sign one, then you should contact a workers' compensation attorney immediately, and let the attorney deal with the insurer.

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