Top Five Workers’ Compensation Denial Reasons

Insurance companies state that Claims Examiners pay about 80 percent of workers’ compensation claims. This claim is very misleading. There’s a big difference between paid and paid in full. Insurance companies often cite one of the reasons listed below, even if the rationale for denial is very weak, and then pressure victims into settling their claims for pennies on the dollar. Sadly, this tactic usually works, as the alleged “paid” rate clearly shows.

A Tampa workers’ compensation lawyer completely short-circuits this common tactic. An attorney reviews and evaluates your claim, so you know for sure how much it is worth. If the insurance company refuses to pay maximum compensation, which it almost always does, an attorney advocates for you and forces the insurance company to settle the claim on victim-friendly terms.

Not a Work-Related Injury

This denial reason is very common in hearing loss and other occupational disease claims. It’s very difficult, even for most doctors, to pinpoint the exact cause of a long-term disease.

A Tampa workers’ compensation attorney doesn’t connect a job injury victim with just any doctor. Instead, lawyers connect victims with medical experts who are fully qualified to give such opinions. Additionally, under the law, a condition need not be exclusively job related. Workers’ compensation benefits are available if a job hazard substantially caused the victim’s illness or injury.

Ineligible Condition

Post Traumatic Stress Disorder is a brain injury that doesn’t fit neatly into the traditional “brain injury” cubbyhole. Therefore, many adjusters deny PTSD claims and hope the victim doesn’t appeal the denial.

Some long-term occupational diseases also fall into this gray area. Emergency responder smoke inhalation is a good example. In the long term, people who inhale toxic smoke often develop cancer and other serious health problems. Florida lawmakers recently updated the requirements in this area. An employer’s insurance policy might or might not reflect these updates.

No Supporting Medical Bills

Florida job injury victims now have the right to see doctors that they choose, not a doctor on a list that an employer or insurance company provides. We urge job injury victims to exercise this right. A lack of proper documentation makes it very easy for claims examiners to deny claims. There is no reason to make a Claims Examiner’s job easy.

Horseplay

This workers’ compensation defense has two basic elements: the activity was completely unrelated to the job and the activity was likely to cause injury.

Assume Harry and Sally race to see who can clean up their work area first, and Harry dislocates his shoulder. A Claims Examiner would almost certainly claim that horseplay caused Harry’s injury. However, a race could possibly cause injury, but it isn’t likely to cause injury. Additionally, Harry and Sally’s race was work-related, at least to an extent.

Drug/Alcohol Use

If employers have clear, written policies that forbid alcohol or drug use during work, or working while under the influence of drugs or alcohol, this defense might hold up in court. In these situations, and only in these situations, a Claims Examiner could validly deny a workers’ compensation claim.

 Reach Out to a Hard-Working Hillsborough County Attorney

Injury victims are entitled to important financial benefits. For a free consultation with an experienced job injury lawyer in Tampa, contact Kobal Law. We do not charge upfront legal fees in these matters.

Source:

insurancebusinessmag.com/us/news/workers-comp/common-reasons-why-workers-compensation-claims-are-denied–and-how-to-avoid-them-428672.aspx