Having a workers’ compensation claim denied can be a shocking and frustrating experience. For many working people, workers’ comp is the best or only available resource for getting care for an injury or illness that happened on the job. When someone can’t keep working or needs long-term care, denied coverage can have profound personal consequences. Here are some of the common reasons why an insurer will deny a claim.
- The injury or illness is not eligible for benefits.
To be eligible for workers’ compensation coverage, an individual must have been injured or contracted a disease in the course and scope of employment. Workers’ comp is a no-fault form of insurance, which means that an insurer cannot base decisions about whether to approve a claim on the degree to which the employee or someone else is responsible for the injury or disease. But insurers do look closely at the circumstances of the claim to verify that the individual who makes it was in fact working at the time of the injury. Cases involving denied claims have included employees who are injured while commuting, on a lunch break, or between shifts. But the dividing line between work and not-work is not always clear, and sometimes a dispute can arise when, for example, an employee is injured on the way to an employer-provided break room
- Missed deadlines and incomplete paperwork.
The insurance adjusters who evaluate the merits of claims are paid to review every detail for breaches of legal requirements. When claim paperwork is submitted late, or required pieces are missing, an insurer may have an excuse for denying an otherwise valid claim. For example, an accident at work needs to be reported to the employer within seven days.
- Suspicious discrepancies.
Insurers are passionate about guarding against fraud. If they think that a claim is based on misinformation, they will be quick to deny it. Workers can find themselves facing a denied claim if information they provide in their paperwork doesn’t match third-party records, such as those provided by the employer or the physician who conducts the initial evaluation. Injured workers are also getting into trouble by posting contradictory information to social media accounts.
- Evidence of drugs or alcohol use.
A workers’ compensation insurer can deny an employee’s claims if it finds evidence that the employee was drunk or under the influence of a controlled substance at the time of the workplace injury. This includes recreational marijuana
use. An employee can only overcome the denial of a claim on the basis of drugs or alcohol use by showing through clear and convincing evidence that the substance was not a factor in the employee’s injury. Although the facts of an injury may support the employee’s argument, the process will be significantly more complicated as a consequence of drug or alcohol use at work.
For over 45 years the law firm of Greenman Goldberg Raby Martinez has represented Las Vegas clients in workers’ compensation claims disputes. We can help you resolve your questions about workers’ compensation coverage and fight back against an insurer that refuses to give you the coverage you deserve. Call us today for a free attorney consultation at 702-388-4476 or send us a request through our site