Why Would Your Workers’ Comp Claim Be Denied? Learn Where Things May Have Gone Wrong

When you’ve been hurt on the job, workers’ compensation can literally save your life. Most employers have it and many common work injuries and occupational diseases are covered.

You got hurt on the job, submitted your claim, and were counting on benefits. But for some reason, your claim was denied. What are some common issues that can derail a workers’ comp claim?

Issue #1: Not Meeting Deadlines

There are some key deadlines when it comes to your workers’ comp claim. For example, if you or your employer’s insurer fail to file on-time paperwork with the North Carolina Industrial Commission (NCIC, the state administrative agency that oversees work injuries), you will receive a denial. Or, if you failed to notify your employer promptly after your injury, your employer or their insurer may now be denying you were hurt at work at all.

Meeting deadlines is a crucial part of your claim and is something an attorney can help you stay on top of. You have 30 days to notify your employer of your injury or illness after onset, but you should do it as soon as possible (and in writing).

After notifying your employer, you must submit additional paperwork called a Form 18 to the NCIC. This should ideally be done within 30 days. Meanwhile, your employer must submit their paperwork in a timely manner, too. If your employer doesn’t do their part, your claim can be denied even if you’ve done yours.

Issue #2: Inaccurate or Incomplete Claim Forms

If you meet deadlines but don’t submit complete and accurate information, your claim could still be denied. Said another way, your claim may be strong, but if you haven’t provided accurate medical records and documentation, the insurance adjuster will not take you at your word. The adjuster needs to see proof that your physical limitations and pain are directly related to the injury or illness you suffered from work.

Proving a direct connection can be especially difficult when it comes to occupational diseases. You must show not only that you’re sick but that your job duties and work environment made you sick. As many diseases take a long time to start showing noticeable symptoms, it is wise to have an attorney on your side who’s familiar with building these types of tricky cases.

Issue #3: Not Going to the Right Doctor or Following Their Orders

Let’s say you’ve met all deadlines and submitted perfect paperwork. Your employer’s insurer agrees to provide benefits…but instead of going to the doctor they assign you, you get treatment on your own. Or you go to a doctor for treatment before you even make your claim and then try to submit your bills for reimbursement from the insurer. Unfortunately, your claim for coverage of that treatment is likely going to be denied.

Another potential issue is if you go to your assigned doctor, but don’t abide by their instructions. For example, your doctor tells you not to lift more than 10 pounds, but the insurance company’s private investigator catches you doing that anyway. Not only can coverage be denied, but a decision to accept a claim can be reversed.

At some point during your recovery, you may want a second opinion from a doctor. Or, you may decide to fight for treatment you believe you need, even if the insurer thinks you don’t. But it’s important to fight these battles and seek authorization beforehand, rather than taking action and hoping for unlikely reimbursement after the fact. Your attorney can help you navigate the difficult stage between the start of your treatment and when you reach maximum medical improvement.

Issue #4: You Weren’t an Employee or Your Injury Didn’t Happen at Work

If you are an independent contractor rather than an employee, you are not eligible for workers’ compensation. However, “employee” can be a hotly-disputed term under workers’ compensation law. Don’t just accept your employer’s designation.

Alternatively, your employer and their insurer may accept that you’re an employee but try to argue that your injury didn’t happen at work. Were you at work if you were on your way to work? Were you at work if you work from home? Your unique case hinges entirely on specific facts surrounding the injury. An attorney can help you fight for compensation when the insurance company is pushing back.

Issue #5: The Insurance Adjuster

The number one reason you may be denied is that the adjuster has extensive training in scrutinizing every tiny detail of your claim. If there is a deadline issue, a question of proof, or a concern over your employment status, the adjuster will pursue it.

Their job is to protect the interests of their employer. As a general rule, if the insurance company pays you less, they get to keep more. You shouldn’t just accept that your claim was correctly denied.

Even if the circumstances of the injury and your employment status are clear, and you’ve submitted everything that’s required of you, a casual conversation with the adjuster can be your undoing. Incorrectly describing something may invalidate your claim even if it’s perfectly valid!

Think Your Workers’ Comp Claim Was Improperly Denied? It’s Time to Take Action

If your workers’ comp claim has been denied, you may need an attorney to help you identify what went wrong and how the two of you may be able to fix it. Many of our workers’ comp attorneys are North Carolina State Bar Board Certified Specialists in workers’ comp law. Our team has the resources, skills, and experience to help you, so call us at 1-866-900-7078. One of our attorneys will evaluate your case for free and let you know how we can help.

 

Susan Vanderweert

About the Author

Susan Vanderweert practices workers’ compensation law in North Carolina for the Law Offices of James Scott Farrin. Previously, she represented the other side – insurance companies and employers – but moved on to fight on behalf of employees. Susan is a North Carolina State Bar Board Certified Specialist in Workers’ Compensation Law, and she was selected by peers to the annual “Best Lawyers”a list for Workers’ Compensation Law in 2021 and 2022 by Best Lawyers in America.

aFor more information regarding the standards for inclusion, please visit www.bestlawyers.com.

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