However, just because workers’ comp is there doesn’t mean that things will always work out the way people expect. Even if you sustain an injury at work, there is still a chance that when you and your employer put in a claim, the insurance company may deny it. But why? Here are three of the most common reasons that workers’ comp claim is denied.
There’s a Discrepancy Between Report & Treatment
The one thing that an insurance company looks for in any legitimate case is consistency. When there’s a lack of consistency, that usually raises red flags that something may be wrong, or in some cases, deliberately altered to make a fraud report.
When an accident at work occurs, a report of that incident is filed from work. When you seek medical treatment for that accident, diagnosis, and treatment occur. A new entry of the findings is made on your medical record. Workers’ comp insurance companies look for consistency between these two documents. If you report, for example, you broke your right leg during the accident, but the medical report declares you didn’t feel your right leg was a problem at all, but that you had an illness instead, that’s too large a discrepancy to ignore.
You Filed A Claim After Ceasing Employment
This will always raise a red flag with a workers’ comp insurer because it seems contradictory. While it is true that some medical conditions take time to emerge, be detectable and diagnosable, timing can be suspect, especially if the claim takes place months—or even years—after the fact.
However, some people will submit a claims file for injury after being laid off or fired. This is a challenging position for workers comp since it is, at least in part, designed to provide a “substitute salary” when someone is incapable of work during medical treatment and recovery. If an employee is no longer working anyway, why should the employer provide coverage?
You Didn’t Provide Statements Or Medical Authorizations
This can be a tricky issue. A statement about your injury to an insurer isn’t legally required, so people don’t have to do this. However, insurers can get suspicious if they ask one and are refused the statement since they want to have on one hand to compare with final medical evaluations.
The medical authorization itself is another area of suspicion. Legally you are required to submit this. However, the insurance company would like to do this instead of letting you do it. There is a fear that if the employee does it, what is submitted to the insurer may be cherry-picked or altered from the actual medical record.
If you have your claim denied, however, that’s not the final word. Talk to a workers’ comp lawyer about your situation and find how out how best to proceed.