The workers’ compensation system is increasingly failing to protect the very people it was designed to help. Employers are required to carry workers compensation insurance to ensure coverage for their employees in the event of work-related injuries and illnesses.
In 2022, there were approximately 3 million workplace injuries and around 5,500 fatalities across the United States. However, companies are increasingly denying claims -leaving employees in trouble. These accidents can happen in the blink of an eye, and knowing how to legally protect yourself can be intimidating.
In Illinois, our lawyers know that navigating this increasingly complex system can be daunting. To ensure you receive the compensation you deserve, a simple place to start is to understand the common reasons as to why claims are denied.
Here are the seven most frequent reasons for workers’ compensation claim denials and how you can avoid them.
1. Incomplete or Inaccurate Claim Forms
One of the most common reasons for a workers’ compensation claim denial is incomplete or inaccurate claim forms. This issue is particularly frustrating because it’s entirely preventable.
Workers need to file accurate and complete claim forms to avoid delays or denials. Workers’ compensation claims rely heavily on the accuracy and completeness of the documentation provided. Even a small error – such as a misspelled name, incorrect date, or missing information about the injury – can lead to significant delays or outright denials.
For example, if you fail to describe clearly how your injury occurred during your job duties, your claim might be flagged for insufficient information. The insurance company may argue that without a detailed account, they cannot verify that the injury is work-related. This can lead to a denial, leaving you without the necessary support during your recovery period.
Pro Tip for Prevention
Double-check every section of the claim form before submission. If you’re unsure, seek assistance from a workers’ compensation attorney to ensure all details are accurate and complete.
2. Failure to Report the Injury on Time
Timely reporting of workplace injuries is not just a recommendation – it’s a legal requirement. In Illinois, state law generally mandates that you report your injury to your employer within 45 days of the incident.
Failing to report your injury within this timeframe can lead to an automatic denial of your claim, regardless of the severity of the injury or the validity of your claim. Additionally, failing to file a claim within the required timeframe can also result in an automatic denial.
Employers and insurance companies often scrutinize the timing of injury reports. If you miss the 45-day window, your employer might argue that the injury did not occur at work or that it’s not as serious as claimed.
Late reports raise red flags, leading insurers to suspect that the injury happened outside of work or that it’s being exaggerated. This suspicion can result in your claim being denied before it even gets properly evaluated.
What to Do if You Miss the Deadline
If you’ve missed the reporting deadline, consult with an attorney immediately. They may help demonstrate valid reasons for the delay and guide you through the appeals process.
3. Insufficient Medical Evidence
The cornerstone of any workers’ compensation claim is the medical evidence that supports it. Comprehensive medical care documentation is essential because it provides the necessary proof that your injury is legitimate, work-related, and severe enough to warrant compensation. Without strong, comprehensive medical documentation, the chances of your claim being approved are significantly reduced.
Workers’ compensation claims require detailed medical records that clearly establish the connection between your injury and your job duties. These records should include the initial diagnosis, treatment plans, progress notes, and any recommendations for ongoing care or rehabilitation. The more detailed and consistent these records are, the stronger your claim will be.
For instance, if your medical records lack a clear description of how your injury is connected to your work tasks, the insurance company might argue that your injury is not work-related, leading to a denial.
Strengthening Your Medical Evidence
Choose a doctor who is familiar with workers’ compensation cases. Ensure your medical records thoroughly document your injury, treatment, and prognosis. If necessary, consider getting a second opinion to bolster your claim.
4. Pre-Existing Conditions
Pre-existing conditions are a common reason why workers’ compensation claims are denied. Insurers often argue that the injury you are claiming compensation for is not work-related but instead stems from a pre-existing condition.
This can be particularly frustrating if your work has clearly aggravated or worsened a pre-existing issue, but proving this connection can be challenging. Proving the connection between work activities and an occupational disease can be complex.
The burden of proof lies with the injured worker. You must demonstrate that your work activities directly contributed to the worsening of your condition. This can be a complex process because the insurer will likely scrutinize your medical history to find any evidence that the condition existed prior to your employment or that it could have worsened on its own without any work-related factors.
How to Prove Your Case
Collect all relevant medical records and demonstrate how your job duties specifically aggravated your pre-existing condition. Documentation is key in proving that the workplace injury is distinct from the pre-existing condition.
5. Lack of Witnesses
Without witnesses, it can be challenging to prove that your injury occurred at work. Employees who witness the incident can provide valuable testimony that corroborates your account of the incident, lending credibility to your claim. Without witnesses, however, it can be significantly more challenging to prove the circumstances surrounding your injury, especially if there’s any dispute about how the injury occurred.
The absence of witnesses can lead to skepticism from your employer or the insurance company. They may argue that there’s no concrete evidence to support your claim that the injury happened at work, which can result in a denial.
This is particularly problematic in cases where the injury wasn’t immediately reported or occurred in a location where it wasn’t easily observable by others. Without someone to back up your story, the insurance company might question whether the injury was indeed work-related or suggest that it could have happened elsewhere.
Alternative Evidence
If no one witnessed your injury, other forms of evidence, such as security footage or detailed accident reports, can be crucial. Even without witnesses, thorough documentation can still support your claim.
6. Disputed Work-Relatedness of the Injury
One of the more challenging aspects of a workers’ compensation claim is proving that your injury is directly related to your job duties. Proving work-related injuries can be challenging if there is any ambiguity. Employers or insurance companies may dispute this connection, arguing that your injury did not occur while you were on duty or that it wasn’t related to the tasks you perform at work.
This can be challenging if there’s any ambiguity surrounding the circumstances of your injury, such as if it occurred during a break, while commuting, or in an offsite location. Disputes over the work-relatedness of an injury often arise in situations where the lines between work and personal time are blurred.
For example, if you were injured during a lunch break while off the premises, your employer might argue that the injury didn’t happen in the course of your employment. Similarly, injuries sustained while commuting to or from work are generally not covered under workers’ compensation, unless you were performing a work-related task during your commute, such as running a work-related errand.
Strengthening Your Case
Gather evidence that directly ties your injury to your job duties, such as coworker statements or task logs. The more you can demonstrate the link between your work and your injury, the stronger your claim.
7. Failure to Follow Medical Advice
After filing a workers’ compensation claim, your responsibility to comply with the treatment plan outlined by your medical provider is very important. Even though your claim may initially be approved, deviating from the recommended medical advice can jeopardize your benefits.
Insurers are vigilant about ensuring that claimants are actively participating in their recovery. If they find evidence that you are not following your doctor’s orders, they may argue that you are not doing everything possible to recover, which could lead to a denial of your ongoing benefits.
The insurance company providing these benefits has a vested interest in making sure that the money they pay out is effectively aiding your recovery. If you skip appointments, ignore treatment recommendations, or fail to take prescribed medications, the insurer may view this as a lack of commitment to your recovery.
They might argue that your continued symptoms or inability to return to work are due to your non-compliance rather than the severity of your injury.
Advice for Injured Workers
Always adhere to the treatment plan outlined by your doctor. Keep records of all medical appointments and treatments. If you face challenges with the treatment, discuss alternatives with your doctor rather than stopping treatment altogether.
Avoid These Common Obstacles and Get the Workers’ Compensation You Deserve
Workers’ compensation claims can be denied for various reasons, but being informed about these common pitfalls will help you avoid them. Accurate paperwork, timely reporting, and thorough medical documentation are a must. If your claim has been denied, remember that you have options, including appealing the decision.
Understanding the available workers compensation benefits is crucial for injured workers.
If you’ve experienced a workers’ compensation claim denial, don’t hesitate to seek legal advice from Midwest Injury Lawyers. Your rights are your rights. We’re here to help you get the benefits you deserve.