Workers' Compensation Claims: Why do they get denied?
Workers' compensation insurance is meant to provide support for individuals who suffer work-related injuries. Since workers' compensation is a no-fault system, employees do not have to prove fault when they have a workers' compensation claim. However, it is not unusual for claims to be denied by the employer or the insurance company. Insurance companies do not enjoy paying out for claims, and employers do not like the possibility of increasing insurance premiums. If you have filed a claim for workers' compensation and it was denied, here are some of the reasons that this might have happened.
Reasons Employers Can Deny Claims
While workers' compensation is a no-fault system where employees can collect benefits even if no one was negligent, or even if the injured person caused the accident through their own carelessness, the claim does have to meet certain requirements in order to be approved.
One of the mistakes injured workers' sometimes make are not properly filing their claim. There are strict time limits, and set procedures for how claims must be filed. If an injured person fails to file on time, or meet other standards required by them, they may lose their ability to collect workers' compensation.
Another requirement is that the injury must have occurred at work. If the employer or the insurance company believes that the injury is actually one that occurred at an earlier time, or outside of work, they might deny the claim. If you aggravated an old injury, they might deny the claim based on their belief that it is a preexisting condition or injury that was not work related.
Also, while the system is not fault based, it is possible for a worker to forfeit their rights under workers' compensation. This can happen if the injury occurred during the course of a criminal act. It can also happen if the injured worker flagrantly disregarded safety regulations and practices, or if the employee was injured in a physical altercation with someone at work, and the injured person was the first aggressor.
While rare, there are cases of workers' compensation fraud. Insurance companies are always going to look for any indication that the claim is not legitimate. This could be the case if the injury did not occur, the employee exaggerated the injury, or the employee claimed they could not work, but actually collected benefits while working a second job.
Things that insurance companies look out for to find false claims
Certain things that appear on claim forms will alert an insurer that something might be amiss. While these things do not mean a claim is illegitimate, and often appear on forms filed by people who are eligible to recover workers' compensation, if an insurer spots more than one of these, they might view the claim with added scrutiny.
- Timing - A claim filed on a Monday morning, and claims filed late will sometimes be viewed with skepticism.
- Medical care issues - If the injured worker did not seek treatment, refused treatment, saw a questionable practitioner, or changed doctors, the insurance company could be suspicious. Also, if a claimant has filed multiple claims for workers' compensation in the past, insurers will likely investigate the new claim.
- Lacking or conflicting evidence - Insurers will want to further investigate a claim when descriptions of the event conflict with one another, or there were no witnesses that can back up a story.
- The claimant's behavior questionable - Insurers will question claimants who are difficult to reach, recently switched jobs or moved.
Thus, if you have been injured at work, let your employer know as soon as possible and contact one of our attorneys at Montlick & Associates to learn about your legal rights as well as what steps are necessary to protect those rights. If you believe your claim was improperly denied, you likely have the opportunity to appeal. Consult with an experienced attorney to discuss the appeals process and your claim.
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If you have been injured at work, call Montlick & Associates, Attorneys at Law for your free consultation today. Montlick & Associates, Attorneys at Law 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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