7 Reasons Why Workers’ Compensation Claims Get Denied and How to Appeal

It seems easy. You were injured on the job. You file a claim for workers’ compensation benefits. You think all you have to do is wait for your benefit check to arrive. Then, you get zapped with reality. The workers’ compensation insurer has denied your claim. You are stunned. You do not understand why your claim was denied.

There are a few main reasons a claim may be denied. Do not despair. In most cases, you can appeal the denial. Unfortunately, you cannot appeal a denial based on a claim you filed after the deadline date.

Insurance Companies and Denied Claims

Almost all insurers have a reputation for denying claims. They are in the business in order to make money, not to pay out claims. But, there are a number of reasons why insurers deny workers’ compensation claims. Some of them are legitimate. Some of them may lead you to contact a workers’ compensation attorney and pursue an appeal.

Some reasons why claims get denied, and for which there is really no avenue of relief unless you have proof that you did meet the time requirement, include:

• You did not notify your employer within the required 21 days after you suffered from a work- related injury, or from the date you knew you suffered from a work-related disease.
• You missed any other date required by the work flow of a Pennsylvania workers’ compensation claim.

Denied Claims and How You can Appeal

Other reasons claims are denied, but provide you the ability to seek relief on appeal include:

1. Insurer claims your injury was not work-related. The insurer may argue that your injury did not occur in the course of your employment. This happens generally if the injury occurred somewhere other than the designated place of employment. You can appeal this and provide evidence that at the time of your injury, you were working on behalf of your employer and the work you were doing was within the course of your employment.
2. A pre-existing condition. The insurer denies your claim, saying you had a pre existing condition that was not made worse by any work-related accident. If the insurer does not deny the claim, it may try to limit your benefits, arguing that the extent of your injury was primarily due to your pre-existing condition. You can rebut this with medical evidence.
3. Mental problems insurer claims were not caused by work environment. If you file a claim for mental stress, be prepared for the insurer to argue that any mental stress you suffer from is not work-related.
4. Intoxication or drug use. This can be appealed, and rebutted, by evidence that: 1) you were not intoxicated or under the influence of drugs at the time of the incident; or 2) the intoxication had nothing to do with the accident. Even if you were intoxicated, that was not the reason for your injury which was caused by a beam falling on your head at a construction site.
5. Lack of medical treatment. If you did not receive, or delayed receiving medical treatment, the insurer will use that as evidence that you were not really injured.
6. Conflicting stories. If you told conflicting stories about how you were injured, that gives the insurer fodder for denying your claim on the grounds that you must have fabricated it.
7. Insurer claims your injury was the result of horseplay. This is grounds for a denial even if the horseplay occurred during business hours at the place of your employment. You can rebut this, for example, by showing that another worker jumped on you as a joke, but you were doing your job and not a participant.

My Workers’ Compensation Claim Was Denied, Who Do I call?

If your claim for workers’ compensation benefits was denied, contact the workers’ compensation attorneys at the Georgelis, Larsen & Sabatino Injury Law Firm, P.C. We will walk you through your options including how and whether you can appeal your denied workers’ compensation claim. There is no charge for meeting with us, and we will take all of the time you need to explain your options and answer your questions.