Workers’ Compensation Claim Denied? Here are 4 Reasons Why

Often, we get calls from clients who filed their own workers’ compensation claim. Sadly, they’re calling to tell us that their claim is denied. While a denied claim may shock the caller, it’s less shocking to us because we also experience instances when we file a workers’ compensation claim for our client and receive notice from the workers’ compensation insurance company stating that the claim has been denied. Why are the claims being denied? Unfortunately there’s no easy answer to that because there are many different reasons a workers’ comp claim can be denied.

Workers’ Compensation claims are denied for hundreds of different reasons, that's why you need an attorney. Click To Tweet

Although there are many reasons for denial, there are a handful that occur over and over. So for now, we’re only going to discuss the four most common reasons a workers’ compensation case is typically denied. Keep in mind that denied, in this context, means that the insurance company refuses to pay benefits. It doesn’t mean you’ve gone to a hearing and literally lost the workers’ compensation claim. When a claim is denied by the insurance company, we usually file for a hearing and take the case to court.

 

The four most common reasons for denial of a claim:

  1. Your employer says the accident never happened or it didn’t happen the way you say it did.
  2. The insurance company hasn’t received the appropriate documentation to prove your injury. To prove a workers’ compensation case, the insurance company needs to receive medical records documenting your injury. If they don’t have any medical records, or sufficient medical records, they’ll deny the case until you provide them with sufficient medical records.
  3. Your employer states they weren’t notified of your injury. It’s extremely important you immediately notify your supervisor the moment you know you’ve been injured at work. Tell your supervisor what happened and what your injury is.
  4. Your employer doesn’t have insurance coverage. If your employer isn’t up-to-date on their insurance premiums, the policy will lapse (be cancelled) and that will cause a denial very quickly.

Remember,  while these are the four most common reasons we see denials in workers’ compensation claims, there are hundreds of other reasons too. But there’s still hope if your claim is denied.

 

Fighting a Workers’ Comp Denial

In Maryland, there are a few steps involved that you and the Insurance Company have to do. The first step is to file an Employee Claim Form with the Maryland Workers’ Compensation Commission.  In most cases, you only have (two) 2 years from the date of your injury to do so.

In most cases, you only have (two) 2 years from the date of your injury to fight a workers’ comp denial. Click To Tweet

Once you’ve filed the Employee Claim Form with the Commission, the Commission will notify the Insurance Company that if it wishes to challenge your case, that it must file “Contesting Issues” with the Commission. If the Insurance Company fails to file Contesting Issues in a timely manner you could win parts of your case by default.

It is, however, rare for the Insurance Companies to miss deadlines – so do not count on this happening. Therefore, when the Insurance Company files the Contesting Issues, the Commission will view that as a request for a hearing and thus, a hearing before the Commission is scheduled.  After a full hearing, the Commission decides whether the Insurance Company’s denial stands or, whether they’re ordered by the Commission to pay your benefits.

It is not advisable for anyone to file an Employee Claim Form with the Commission . . . or worse . . . go to a hearing . . . without the assistance of a skilled Workers’ Compensation attorney.   Contested claims often involve complicated legal issues.

In D.C., the first step is to file an Employee’s Notice of Accidental Injury or Occupational Disease form and an Employee’s Claim Application form with the District of Columbia Office of Workers’ Compensation (OWC).

While the deadlines can vary greatly, we recommend that these forms be filed within 30 days of your injury. You should also provide a copy of each form to your employer within 30 days of your injury. Once the forms are properly filed with the OWC, the Insurance Company will have a set number of days to file a Notice of Controversion with the OWC if they still want to challenge your claim.  If they do file a Notice of Controversion, the legal process becomes very complex and it is in your best interest to hire an experienced Workers’ Compensation lawyer immediately.

If you have any problems with your workers’ compensation claim, and haven’t hired a lawyer yet, please contact us for a free consultation.