The Top Five Reasons Your Workers Compensation Claim was Denied & How to Appeal

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. 

Why Your Claim May Have 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.

Whenever you report an injury, whether it is a fall, a trip or something else, the details can be very important.  Reporting conditions like wet surfaces, poor lighting, working in tight spaces or actions that require you to contort your body into an akward position that contributed to your injury can make all the difference as to whether your claim might be accepted or 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.

The insurance company would have to get you back to “baseline”.  This means that if you have a compensable work injury claim, the insurance company would need to cover medical treatment to return you to where your health was prior to the work accident.

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 (https://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!).

Sometimes the insurance company will ask you to sign a release that is far over-reaching, and this can make folks uncomfortable.  If that happens to you, you can call the insurance adjuster and ask them for a limited releases so they can look at relevant records, whilst not exposing your entire credit report, criminal history and so on.

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.

Other Reasons Your Claim May Be Denied

• Your injury didn’t actually occur at work or while on the clock, such as while traveling to or from work.
• You cannot show the injury occurred at work or is related to the duties of your job.
• You spent more time away from work than was necessary.

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.

The Legal Appeals Process

If your claim is denied, the appeals process is available to help you fight back when you feel that you were unjustly refused the benefits that you deserve. Having a workers’ comp attorney in Richmond on your side can help you through the process.

The appeals process in Virginia is quite simple. You must file within 30 days of the Review Opinion. This can be done by mail or in person, and it includes a $35 fee unless you file a Motion to Waive the Appeal Bond. Copies of the appeal must be sent to every party involved. Claimants must also file with the Court of Appeals, which includes a $50 filing fee. This may be waived due to financial hardship if a request is submitted in writing.

Claimants are also responsible for a $500 Appeal Bond, which must be paid with your Notice of Appeal filing in the Court of Appeals. Again, if you cannot pay this security bond due to indigence or disability, there is a Motion to Waive. Otherwise, the payment must be made in the form of a cashier’s check or a surety bond from an insurance provider that is licensed within the state of Virginia.

Claimants will also need to file a brief, which has a specific due date that the Court of Appeals will notify you about in writing. You can contact the Court directly for an extension on this filing if you don’t have sufficient time to file this brief. Finally, a failure to follow these procedures can result in dismissal of an appeal.

The Value of a Workers’ Comp Attorney in Richmond

Because of the legalities involved in the appeals process, it is important that you know exactly what you are doing. Having a Richmond workers’ compensation lawyer on your side can help through this process. A lawyer knows the process and understands what it takes to get an appeal filed properly. This may also increase the likelihood that your appeal is not only filed but also ruled in your favor.

Workers’ compensation is supposed to be there to protect you when something goes wrong. However, because of all of the technicalities and legalities involved, it can be hard to get the outcome that you deserve the first time around. If you feel that your claim has been denied unjustly, you can file an appeal in the state of Virginia for a second chance to get the compensation and justice that you deserve. Make sure that you have a workers’ comp attorney in Richmond to help you through the process, so that it is easier and you have a better chance at success.

Workers’ Comp Works Hard to Avoid Fraud

Most of the legalities in your workers’ compensation claim are a result of people filing fraudulent claims or trying to get more than they’re entitled to with a claim for workers’ compensation. Because of this, it can be easy for claimants to feel like the guilty party when, in reality, they are the victim. Call a workers’ comp attorney in Richmond to help you over the hurdles of your workers’ compensation claim so that you can get the best outcome.