Common Reasons for Workers’ Compensation Claim Denials
Workers' compensation programs are meant to help employees who suffer an injury while they are carrying out their work related duties. While employers benefit from workers' compensation programs, which allow them to avoid lawsuits from employees, employees benefit by not having to show that their employers were negligent. In fact, even if an employee carelessly causes his or her own injury, workers' compensation is meant to cover that employee as long as the injury was in fact related to work. Because these programs are meant to reduce the burden of work related injuries on employees, it can be a frustrating and confusing situation when an employee finds that his or her very legitimate workers' compensation claim was denied. In reality, a surprisingly large number of workers' compensation claims are in fact denied. There are several reasons why this might happen.
Insurers and employers do not want to pay claims
This is a pretty general reason, but it is important to remember that the money that goes to pay for a workers' compensation injury comes from somewhere, usually, an insurance company. These companies are not eager to pay out settlements, and employers are not eager to have their rates rise. As such, despite the "no fault" aspect of workers' compensation, insurers will not blindly pay out claims, but rather will evaluate them and look for any facts that might allow them to refuse to pay.
Procedurally, the injured person made a mistake
Workers' compensation claims have timelines. A person who suffered from an injury must report the injury and file the claim within the time frame. In the event that the injury occurred in an accident, the clock begins running right away, and depending on the state, the claimant might have a few weeks or a month to file. Failing to file on time can mean the claim will be denied.
In the case of illnesses and chronic injuries, the timeline is altered, and will typically start when the person (1) knew or should have known that they suffered an injury or illness, and (2) knew or should have known that it was work related. So if the injury was chronic carpal tunnel syndrome, for example, a diagnosis might start the clock.
Another procedural factor is that injured employees are sometimes required to undergo physical exams to determine if their injuries are valid. In these cases, if the employee fails to attend the appointment for such examinations, the claim might be denied.
It is therefore important to ensure that you are following the procedure properly. Our attorneys at Montlick & Associates can advise you on procedure as well.
The insurer thinks you are lying or exaggerating
Sometimes, an insurance company might find a reason to claim that the injury that you sustained was actually an old injury, or one that was caused outside of work. For instance, if you say you suffered an injury from falling at work on Monday, but they see on social media that you were in an accident on your dirt bike the previous Sunday, they might deny your claim on the grounds that they believe your injury was not work related.
Claimants can face problems if they do not see a doctor for their injuries in a timely manner. If the insurer sees that you fell and supposedly suffered serious injuries at work, but did not see a doctor for two weeks, they might be skeptical of your claim.
If you do find yourself in the position of having your claim denied, you typically will have the opportunity to appeal that decision. If you were involved in any work-related injury, our attorneys at Montlick & Associates can examine the facts and circumstances of what happened and advise you on what steps are necessary to protect your rights.
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If you have been injured at work, call Montlick & Associates, Attorneys at Law for your free consultation today. Montlick & Associates has been representing those who suffer serious injuries throughout all of Georgia and in the Southeast for over thirty-three years, including but not limited to Albany, Athens, Atlanta, Augusta, Columbus, Gainesville, Macon, Marietta, Rome, Roswell, Savannah, Smyrna, Valdosta, Warner Robins and all smaller cities and rural areas in the state.
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Montlick & Associates, Attorneys at Law
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Atlanta, GA 30329
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