The Top Five Reasons Your Workers Compensation Claim was Denied

Claim denied

Workers’ compensation insurance companies make the initial determination as to whether your work injury claim is approved or denied.  The insurance companies like to deny work injury claims all the time – sometimes for a valid reason but most of the time because the insurance companies are hoping injured workers will just take their word for it and move on (and, in turn, saving the insurance company millions of dollars each year). I have listed some of the most common reasons workers’ compensation insurance companies will give to injured workers as their justification for stating that their work injury claim has been denied.

Non-Compensable Injury

This means that, according to the insurance company, your injury does not meet the requirements in Virginia for being covered as a workers’ compensation injury. Often, insurance companies will use the “non-compensable injury” language for some of the reasons below, as well. I can’t say for sure, but I think insurance companies like to use this “non-compensable injury” term because it is vague and it can be confusing to injured workers who may not be familiar with Virginia workers compensation law and the claim process.

Unexplained Injury

If you were injured at work, you need to be able to say HOW the happened. I like the example of a fall: If you fall at work, you need to be able to say why you fell!  If you say “I just fell,” the injury will not be covered. The insurance company is well aware that if the injury was not related to work (what is often referred to as “unique to the job”) they don’t have to cover it. If you say you just fell and you don’t know why, the insurance company might just assume that you are clumsy and, therefore, they are not responsible under Virginia law. However, if you fell because you tripped over the employer’s floor mat or because there was moisture on the floor and YOU REPORT THE INJURY THIS WAY, then it can be covered by workers’ compensation and your claim shouldn’t be denied.

Pre-Existing Injury

Insurance companies love to use this as a reason to deny a work injury claim. They tell injured workers that because they have had ongoing back problems for years, that they are not going to cover medical treatment to their back after their work injury. This is not true! Virginia workers’ compensation Rules clearly state that if an injury at work aggravates or exacerbates a pre-existing injury, the treatment can be covered by workers’ compensation insurance.

No Supporting Medical Documentation

Insurance companies have the right to review your prior medical history, as well as any medical records related to your work injury claim. If you refuse to sign the appropriate medical releases or if the records are not provided to the insurance adjuster, the insurance company can use this as a reason to deny your work injury claim. I get several calls a month from injured workers who say they have sent their medical information to the adjuster on numerous occasions but the adjuster still claims they have not received them. I typically tell folks a good way to avoid this is to not only send the information to the adjuster directly but also to the Virginia Workers’ Compensation Commission. Why? Because, once you have done this, the records are on file with the Commission and all parties to the claim will have easy access to these via the Commission’s Webfile portal on the Commission’s website (http://www.vwc.state.va.us/).  Webfile is the Virginia Workers Compensation Commission’s online repository of documents (kind of like online banking but for your Virginia work injury paperwork!).

Failure to Report the Injury

Injured workers tell me all the time that they reported their injury to their employer a day or a week after the incident took place. It is not uncommon for insurance companies to tell injured worker that because their injury was not reported right away their claim is denied. I say bologna!! The State of Virginia says that in order to qualify for workers’ compensation benefits, the injury must be reported to the employer within 30 days of the accident. Your employer may have their own policy on reporting injuries and the time limits associated with this but even in these situations the Rules in Virginia say you can still get benefits if the injury is reported to your employer within the 30 day time period. Even with the 30 day Rule, I always tell injured workers it is better to report an injury as soon as possible.

If you were told your  work injury claim was denied for one of the reasons above and you want an attorney to review the situation, call my office for some guidance.  My staff is standing by to take your call.

If you have questions about your benefits or if you would like more information on the workers’ compensation system, order my book, “The Ultimate Guide to Workers’ Compensation in Virginia”, or call our office today (804) 755-7755.

 

2018-07-18T19:05:42+00:00

About the Author:

The Injured Workers Law Firm is a Richmond, Virginia based firm solely focused on serving clients with workers' compensation claims in Virginia. If you have questions about your benefits or if you would like more information on the Virginia workers’ compensation system, order our book, “The Ultimate Guide to Workers’ Compensation in Virginia” , or call our office today (804) 755-7755.