Reasons Why Workers’ Compensation Claims are Denied

Aug 02

Employees in non-exempt companies believe that if they incur work-related injuries they are covered by workers’ compensation insurance, as mandated by law. However, there are instances when a claim will be denied, and it can be a very upsetting experience to get a letter stating that this is so and why.

There are several reasons why a workers’ compensation claim will be denied. The most common would be that the claim was not filed within the time frame required by law, which is typically within a few days. Depending on the state, the employer may be required to do the filing, or the employee can go directly to the insurance carrier to file a claim.

The claim may have been denied because the employer disputed the claim. This could be because the employer alleges that the injury or illness is not work-related, or that the accident did not occur at the workplace. In such cases, the employee will have to produce evidence to the contrary, such as statements from witnesses, or certification from a doctor that the injury or illness is work-related.

Another reason a claim may be denied is because the state does not recognize the injury or illness as eligible for workers’ compensation. In some states, stress-induced conditions are precluded. It may also be that the severity of your condition does not meet the criteria set in the insurance policy.

However, even if a claim is denied, an employee can still appeal. This process of appealing may vary from state to state. In Oklahoma, for example, the employee must file a petition with the Office of Workers’ Compensation within two years after the initial claim is denied. An Oklahoma workers’ compensation lawyer would ideally be the one to draft and file the petition to make sure that it complies with the state’s requirements, otherwise the claim could delayed and further delay compensation.

If you are employed in Lexington, on the other hand, a denied claim can be appealed by informing the Kentucky Department of Workers’ Compensation that your claim was denied, and to file for an appeal. A Benefit Review Conference will then be scheduled between you and the insurance carrier to iron out any issues. The presence of Lexington workers’ compensation lawyers at this point would be desirable to make sure that your rights are protected and to impress on the insurer that you are in earnest.

In both states, when mediation is unsuccessful, a hearing will be scheduled at which you and your lawyer should present your corroborating evidence to support your claim. While you may file an appeal on your own, it is not advisable as the appeals process is often too complicated and highly technical for an individual with no legal training.

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