Learn why workers’ comp claims are denied so you can protect your right to compensation
The workers’ compensation system is designed to help people who are injured or develop occupational diseases as a direct result of their employment. While the system works well most of the time, there are situations where it doesn’t work as intended.
Many legitimate workers’ compensation claims are denied every year, and people who lack an attorney’s assistance tend to struggle the most.
This article will provide an overview of the workers’ comp process and explain the top reasons workers’ comp claims are denied, so you can avoid the most common pitfalls.
What do workers need to prove about their injury or illness to get workers’ compensation?
Workers’ compensation is a no-fault system, which means that workers don’t need to prove anyone is at fault for their injury or illness to get compensation. To receive benefits, including compensation for medical expenses and lost wages, eligible workers only need to prove that their injury or illness occurred at work or while they were performing their work duties.
Once you get hurt at work, however, it becomes your word versus your employer’s, and unfortunately, some employers try to dispute legitimate claims to prevent their workers’ compensation insurance premiums from increasing.
In order to protect your rights, you’ll need to file an injury report with your employer right away (within 30 days), which will provide documentation of when you first noticed your condition. Additionally, gathering evidence, such as medical records, witness statements and surveillance video footage, as soon as your immediate medical needs are taken care of is often your best defense against a potential denied claim.
How does workers’ comp handle claims for occupational diseases?
Occupational diseases are illnesses that arise from your exposure to risk factors while performing your work duties. Keep in mind that just catching the flu wouldn’t count since it isn’t related to any specific risks posed by your job. However, respiratory illnesses experienced by firefighters or first responders from exposure to hazardous chemicals or fumes would be classified as occupational diseases.
The workers’ compensation system does recognize occupational diseases as being eligible for coverage, but you may find yourself doing some extra work to prove that you got sick from your employment.
Since these diseases usually develop over time, you’ll need to be extra cautious about providing documentation of your medical history along with details about your work duties that connect your illness to your exposure to certain risk factors.
Why would a workers’ comp claim be denied?
Knowing why a workers’ comp claim could be denied helps you take steps to prevent this outcome in your case. If you do receive a denial, understanding the underlying reason enables you to move forward with an appeal.
Below are some of the top excuses employers use to try to deny workers’ compensation claims:
- They claim your injuries aren’t from a work-related accident.
- They recognize that you’re hurt but claim you can still work.
- They claim that your willful misconduct led to the accident.
- They claim your injury was intentional.
- They claim you were injured as you left work and weren’t on the premises.
- They claim you didn’t report your injury or illness within the appropriate time frame.
- They claim that you didn’t get treatment from an approved medical provider.
- They claim your injury comes from a pre-existing condition.
- They claim you’re an independent contractor and are not eligible for benefits.
- They claim there are notable discrepancies in your accident or injury report that cast doubt on the legitimacy of your claim.
- They claim you initiated a fight that caused your injuries.
- They claim you were under the influence of drugs or alcohol at the time of the accident.
Additionally, workers without legal representation are often more likely to have their claims denied. Hiring an experienced workers’ compensation attorney as your advocate will ensure that all involved parties are accountable and procedures are followed.
What evidence is helpful for proving a workers’ compensation claim?
Insurance companies commonly use the tactic of questioning whether a person’s injury is truly work-related to deny claims. This tends to happen more often with injuries such as carpal tunnel syndrome that develop slowly over time.
In these situations, a doctor’s testimony is especially effective for describing how your injury is related to your job duties. You might also use medical records, witness statements and surveillance footage to prove your claim. Time cards and other long-term forms of record keeping can also be helpful in cases that involve repetitive stress injuries.
How an attorney can prevent a workers’ comp claim from being denied
An attorney can help you avoid a denial from the very beginning by helping you fill out necessary paperwork and making sure that you meet the filing deadlines. Attorneys also know the red flags that insurance companies look for regarding work-related injuries and occupational disease claims, and they’ll gather medical information and other evidence that supports your need for compensation.
What steps should I take if my North Carolina workers’ comp claim is denied?
If your workers’ compensation claim is denied, it’s important to act promptly and strategically to protect your rights and pursue the benefits you’re entitled to. At this point, it’s best to cease communication with your employer and their insurance company regarding your claim and allow an attorney to handle the majority of your case.
Here’s what you need to do if your workers’ comp claim is denied:
- Understand the reason for denial. Carefully review the insurance company’s denial letter so you can understand why they denied your claim.
- Seek legal advice. Consult with a workers’ compensation attorney experienced in North Carolina law. An attorney can provide valuable guidance, help you understand your options, and represent you throughout the appeals process.
- File a formal appeal. Next, you’ll need to notify the North Carolina Industrial Commission (NCIC) (the agency that oversees workers’ compensation disputes) of your intent to appeal the denial by filing Form 33, “Request That Claim Be Assigned for Hearing.”
- Work through mediation. In most cases, the NCIC will require or suggest mediation before the hearing. Mediation is a process where a neutral third party helps the involved parties reach a settlement agreement.
- Prepare for the hearing. If a satisfactory agreement cannot be made, the next step is to prepare for a hearing before a Deputy Commissioner of the NCIC. Your attorney will gather evidence, including medical records, witness testimony and other relevant information, to support your claim during this time.
- Attend the hearing. During the hearing, both you and the insurance company will present your cases. It’s crucial to be well-prepared and have all your evidence and documentation organized.
- Appeal to the full commission. If the decision by the Deputy Commissioner is not in your favor, you can appeal to a 3-judge Full Commission of the NCIC. This appeal is based on the record from the hearing, along with written arguments.
- Further appeals. If necessary, you can appeal the Full Commission’s decision to the North Carolina Court of Appeals and, ultimately, the North Carolina Supreme Court.
Navigating a denied workers’ compensation claim can be complex and stressful. Having an experienced attorney can significantly increase the likelihood of a successful outcome of your appeal and help ensure that your rights are protected throughout the process.
Contact a Charlotte workers’ compensation attorney
Working with an attorney from the very beginning can help you to avoid an initial denial so you can get the compensation you need for a full recovery. Even if you receive a denial form, it’s often not too late to get the compensation you deserve. Our Charlotte workers’ compensation attorney can help you address the reasons for the denial and improve your chances of reaching an acceptable settlement.
At Wilder Pantazis Law Group, our knowledgeable work injury attorneys are committed to helping workers in North and South Carolina recover maximum compensation for their injuries. We offer free initial consultations, and we work on contingency—so you won’t pay a fee unless we win your case.
Contact us today for your free no-obligation consultation to see how we can help you.