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Why Are Some Worker’s Compensation Claims Denied?

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Occasionally, worker’s comp benefits can be denied. Although worker’s comp claims do not require the claimant to prove fault, they do require extensive documentation of employment and medical injury. There are some cases in which the denial is legitimate, and some cases where it is not.

Denied worker’s comp claims can, however, be appealed with the help of experienced California workers’ compensation attorneys. Lawyers can investigate if the reason for denying your claim is legitimate and assist you in the appeals process to get the compensation you need. If you filed a worker’s comp claim and it was denied, it may have been for one or more of the following common reasons:

The Injury Did Not Happen at Work

The most common reason for denying worker’s comp benefits occurs when it is found that the injury did not actually occur at work. This usually indicates the employee is intentionally dishonest by claiming that the injury happened at work when it in fact happened outside of the work schedule and not at the job location.

The Injury Happened When Traveling to or From Work

Unfortunately, injuries sustained while commuting to or from work are not usually legitimate for worker’s compensation. However, there are exceptions to this rule. If the employee was providing their employer with a benefit, such as delivering a parcel or running office errands, the claim is legitimate. If, however, the employee was simply traveling to work, the claim can be denied.

No Medical Justification

Similar to a personal injury lawsuit, a worker’s comp lawsuit requires the claimant to document all medical treatment for it to be covered. Once an employee’s condition improves, he or she is considered healed and able to return to work. If the employee decides not to return to work, he or she does have the right to seek additional medical treatment, but will need to undergo a third party medical exam. If the exam finds the worker is in full health and able to work, any further worker’s comp benefits will be denied.

Statute of Limitations

Every state has different limitations on filing worker’s comp claims. The state of California requires that any worker’s comp claims must be filed within 1-5 years, though your employer must be notified of the injury within 30 days.

If a reported injury sustained from 2 years ago leads to new medical problems, you are eligible for benefits. However, if you never filed a report with your employer, your benefits will be denied. There are some exceptions to this clause, like if the injury resulted in an inability to file a claim, like a coma, or injuries that require long-term treatment or are contagious and require quarantine. No matter when the injury happens, it is imperative to report it to your employer and doctor as soon as possible and keep adequate documentation.

No Documented Medical Treatment or Insufficient Documentation of Work-Related Injury

If an employee is injured on the job and does not receive medical treatment, they have no eligibility for benefits. It doesn’t matter if the employee missed three weeks of work because of the injury. If there is no documented medical treatment, there will be no compensation.

Similarly, if the medical treatment is documented, but there is no documented relation between the injury and the workplace, the claim may be denied. For example, if an employee receives treatment for tendonitis or carpal tunnel, and the doctor does not expressly state he or she believes the injury was caused by work, the claim may be denied. However, the employee does have the right to seek further medical opinions.

If you have filed a claim for worker’s comp and your claim was denied, you may be able to appeal the decision. Contact our competent California workers’ compensation attorneys today for a free consultation.