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Three Reasons Why Your Workers' Comp Claim May Be Denied

Workers' compensation is designed so that employees can get expenses related to injuries from on-the-job accidents paid for regardless of who may be at fault for the incident. However, that doesn't mean your claim will automatically be approved for benefits. Here are three reasons why your workers' comp claim may be denied and what you can do to avoid this situation.

Your Employer May Object

One common reason why a workers' comp claim may be denied is when employers file disputes against claims. One explanation your boss may give the insurance company is you didn't sustain the injury while at work or while performing your duties as an employee.

This can happen in cases where employees fall ill due to exposure to toxic substances (e.g., cancer from inhaling asbestos) or sustain repetitive stress injuries (e.g., carpal-tunnel syndrome). The employer may argue the worker was exposed to the hazards outside of the workplace. You'll need to prove explicitly or upon a preponderance of the evidence that your injury was most likely caused by the conditions at your job.

Another thing an employer may claim is that the injury was the result of the employee's willful misconduct, which is typically not covered in many states. Some willful misconduct is fairly obvious. For instance, workers' comp in Georgia will deny claims for injuries arising from fighting or horseplay.

However, employers may try to use this excuse if employees test positive for drug or alcohol usage at the time the accident occurred, stating that being drunk or high constituted willful misconduct. The thing is, in most states, drug or alcohol usage can only be used as a disqualifier if it contributes in a significant way to the accident. If you fell off the ladder because you were drunk, then you may be denied coverage. On the other hand, if the accident would have occurred regardless of your intoxicated state, then you are still entitled to benefits. You would just have to show the drugs and alcohol had little to nothing to do with the incident.

The Condition Is Not Covered

Another reason why your claim may not be approved is because your condition is not covered. The insurance provider will typically have a list of factors that make an injury or illness eligible for benefits and a list of conditions that aren't covered. For example, stress-related claims are either not covered or have such a high standard of proof that qualifying is nearly impossible.

In this case, it may be possible to still get approved for compensation using other aspects of the injury. Stress may not be an eligible condition, but conditions such as depression are. You could be approved for benefits if you can prove your depression is the result of conditions at your place of employment.

You Don't Meet Minimum Requirements

A third issue that can impact your ability to obtain workers' compensation benefits is failing to meet the minimum requirements for filing a claim. Some states require employees to files claims within a certain number of days after the incident (e.g., within 30 days in California). Failure to file within that time period may bar employees from receiving benefits for that particular injury forever. Sometimes states require employees to be seen by a health-care provider who will evaluate the seriousness of the injury. If workers fail to get the required medical care, then they may not receive benefits.

It's essential that you research the rules in your state and follow them to the letter to protect your rights and ensure you receive the best chance of receiving payment for your injuries.

For more information about these issues or help with a workers' comp claim, contact an attorney, such as one at Whiting, Hagg, Hagg, Dorsey & Hagg.