When someone gets hurt on the job, filing a workers’ compensation claim is often the next step toward getting medical care and wage support. But not every claim is approved. Many injured workers are surprised to learn their claim has been denied, even when the injury seems obvious. There are common reasons why this happens, and knowing them ahead of time can make all the difference in preparing a strong claim.
Delays In Reporting The Injury
One of the most frequent causes of denial is a delay in reporting the injury. Most states have strict rules about how quickly an incident must be reported to an employer. Waiting too long, whether due to uncertainty about the injury’s severity or fear of losing a job, can lead to the claim being tossed out before it’s even reviewed. It’s important to notify a supervisor or manager as soon as possible after an injury, even if symptoms seem minor at first.
Lack Of Medical Documentation
According to workers’ compensation lawyers successful claim relies heavily on medical records. If the medical documentation doesn’t match the timeline or details of the incident, it can raise doubts about whether the injury is work-related. In some cases, workers may seek treatment from a provider not approved by their employer’s insurance network, which could result in the claim being rejected. Keeping consistent records and following the right treatment channels is key.
Disputes About Whether The Injury Is Work-Related
Sometimes the insurance company will deny a claim if it believes the injury didn’t happen at work. If there are no witnesses or if the injury occurred during a break or commute, insurers may argue that it doesn’t qualify for coverage. Even when the injury occurred on the job, the insurance company might assert that it resulted from a pre-existing condition or off-the-clock behavior. Gathering supporting evidence from coworkers, supervisors, or surveillance footage can help confirm what actually happened.
Missed Deadlines During The Claims Process
Filing a claim involves more than just reporting the workplace injury. Workers must often complete paperwork, attend medical evaluations, and submit to questions from the insurance carrier. Missing a deadline for any of these steps can result in denial. We always advise clients to keep copies of everything and to follow up if they’re unsure whether something has been submitted on time.
Inconsistent Statements
Another issue that can lead to denial is inconsistency. If the worker’s account of what happened doesn’t match medical records, employer reports, or witness statements, it may appear dishonest. Even small differences in the description of events can be used to challenge a claim. Staying honest and accurate from the beginning can prevent this from becoming a problem.
Suspicions Of Fraud
While rare, some claims are denied based on suspected fraud. This might happen if an injury seems exaggerated, if surveillance shows the worker engaging in activities inconsistent with their claim, or if the worker has a history of questionable claims. Even when the claim is valid, anything that appears unusual can lead to increased scrutiny.
How Legal Support Can Help
Attorneys like those at our friends at Hickey & Turim, S.C. can attest to how common claim denials are, and how often they’re preventable. Having representation that understands the process and knows how to respond to a denial can increase the chances of success in an appeal. While not every denial is unjustified, many stem from simple missteps that could have been avoided with the right guidance.
If your workers’ compensation claim was denied or you’re concerned about submitting a new one, it’s important to act quickly and confidently. Taking the right steps early on can protect your benefits, your recovery, and your future.