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Common reasons for workers’ compensation claim denials

On Behalf of | Feb 25, 2021 | Workers' Compensation

All workers have the right to perform their jobs in a safe environment. However, there are times when an employee becomes ill or suffers an injury while on the job.

When this occurs, workers’ compensation insurance provides benefits to compensate for medical care and lost wages. Although all employees have the right to file a workers’ compensation claim for an injury, there are times when the insurance company will deny the claim. Depending on the reason for denial, the worker may be able to appeal the decision.

Reasons for denial

According to FindLaw, there are certain steps and timelines a claimant must follow, and some denials occur if they were not pursued correctly. For example, each state outlines within how many days an employee must notify the employer of the injury, and the injured party also has a certain number of days to file a claim, so a denial may occur if too many days passed.

If the injury or illness did not require medical treatment, there will be a denial of the claim. Other denial reasons may include a lack of evidence of a work-related injury or that the injury did not happen at work. Denials also occur if the incident occurred due to a disqualifying reason, such as drug or alcohol use, horseplay or self-harm.

How to file an appeal

If the worker decides to appeal the decision, he or she must follow the deadline supplied in the denial letter. The employee should prepare to provide additional documents, if necessary, to prove the case. This may include an additional medical exam or more evidence of the work-related injury.

According to the State of Connecticut Workers’ Compensation Commission, there are different hearings that a commissioner may use to resolve the claim dispute. About 95% of cases take place at an informal hearing, in which the claimant makes his or her case to the mediator. This person will make a decision based on discussions and evidence. If the two parties do not agree on the decision, or the commissioner is unable to make a decision, the case may move to a formal hearing.