What Can Cause Workers’ Compensation Claims to Be Denied?

You’ve dutifully completed the paperwork for your workers’ comp claim, gathered evidence to support it, and sent it in — only to be met with a denial. It’s an incredibly frustrating experience, and you might not know what to do next. Fortunately, many denied workers' compensation claims can be appealed.

Before you rush to get the appeals process underway, however, it’s important to understand the reason your claim was turned down. Here’s a look at some common causes of workers' compensation denials.

Missed Deadlines

Virginia workers' compensation laws include important deadlines for injured workers:

• You must notify your employer of your injury or accident within 30 days
• You have two years from the date of your injury to file a claim
• In most cases, you must file a claim for an illness within two years of learning the condition is tied to your work
• Most occupational disease claims must also be filed within five years of your last exposure

Some workers’ compensation claim denials can successfully be appealed. However, if you miss one of these key deadlines, you likely won’t be able to recover the benefits you need.

Lack of Evidence

Most workers’ compensation claims are submitted with ample evidence of illness or injury. However, employment insurance providers often reject claims because there’s not enough evidence to prove that the injury or illness was work-related.

If your claim has been denied for lack of evidence, you should consult a workers’ compensation attorney as soon as you can. Lawyers who routinely handle workers’ compensation claims know what types of evidence are most compelling.

While working with an attorney can’t guarantee that your claim will be approved on appeal, having the right legal representation will dramatically improve your chances of success.

Disputes Over Whether the Injury Happened During the Course of Employment

To qualify for workers’ compensation benefits in Virginia, your injury must have happened within the scope of your employment. Determining whether your injury was work-related might seem simple, but it can be surprisingly challenging.

For example, imagine that you have a gradually worsening pain in your shoulder. You can’t pinpoint exactly when it started, but your job involves a good bit of lifting, so you assume it’s work-related.

Because you can’t identify what caused the injury or when it happened, the insurance company could reasonably conclude there isn’t enough evidence to prove the injury was job-related.

Including Offsite Injuries in Your Claim

This is a closely related reason for claim denial. Sometimes, an injured worker will file a claim for an off-site injury because they mistakenly believe it occurred within the scope of employment.

Suppose that you work as a delivery driver. You clock out and run an errand on your lunch break, and you’re hit by a speeding driver along the way.

If you filed a workers’ compensation claim in this situation, it would almost certainly be denied. Although you drive as part of your job, the accident happened when you weren’t on the clock, which means it wouldn’t be covered.

Attributing the Injury to a Pre-Existing Condition

You can typically recover benefits if a work-related injury aggravates a pre-existing condition. However, if the medical evidence you submit with your claim is insufficient, the Workers’ Compensation Commission may rule that your previous condition was the true cause of the injury.

Failing to Cooperate With Evaluations and Treatment

After you file a workers’ compensation claim, you’re generally expected to follow your doctor’s treatment plan and cooperate with the insurance company. If you fail to do either one, your claim could be denied.

It’s important to note that “cooperate with the insurance company” doesn’t mean automatically complying with everything they ask. Like any other insurance company, your employer’s workers’ comp insurance provider may try to twist your words to get out of paying a claim. Always consult a lawyer before talking to the insurance company.

Allegations of Horseplay, Intoxication, or Misconduct

If the workers’ compensation insurance provider alleges you caused your injury through recklessness or misconduct, it may reject your claim. For instance, if you were roughhousing with coworkers around heavy machinery and suffered an injury as a result, you most likely wouldn’t qualify for benefits.

Similarly, your benefits will almost certainly be denied if you were under the influence of drugs or alcohol at the time of the accident. For this reason, many employers drug test employees after an accident takes place.

FAQ

Do I Have to Prove That My Employer Was at Fault for Workers’ Compensation to Be Available?

No. To receive workers’ compensation benefits, you only need to prove that your injury or illness is directly tied to and occurred during the course of your employment.

Can My Workers' Compensation Claim Be Settled?

Yes. However, the Deputy Commissioner of the Virginia Workers’ Compensation Commission must review all settlement offers. A settlement will only be approved if it’s in your best interests.

What Happens if My Appeal Is Denied?

You may still have options. In Virginia, there are three levels of workers’ compensation appeals. You may file an appeal with the state Workers’ Compensation Commission, the Virginia Court of Appeals, and, finally, the Supreme Court of Virginia.

Having Trouble Recovering Workers’ Compensation Benefits?

When you’re trying to recover from a work-related illness or injury, having to deal with a denied claim can feel like one thing too many. That’s where Commonwealth Law Group comes in. We focus on workers’ compensation, civil rights, and personal injury cases, and we’re determined to get our clients the justice they deserve.

If your workers’ compensation claim has been denied and you’re unsure what to do next, contact us to arrange a free consultation and get the skilled guidance you need.