There are many reasons why your workers’ comp claim was denied. Denial rates for workers’ compensation claims have been increasing. However, a recent study showed that 67% of denied workers’ compensation claims are converted to a paid claim. If your claim has been denied for any reason, it is best to consult with an attorney about the specifics of your case to see if you may still have a claim. Here are the most common reasons a claim is denied – most can be overcome with the proper steps and documentation.
1) Failure to Report Accident Timely
Report the injury or illness to your employer immediately. If you fail to report an injury or illness within 180 days, you may be disqualified from receiving workers’ compensation benefits. Injuries requiring only first aid treatment, either on-site or at an employer-sponsored free clinic, do not have to be reported. For an explanation of what constitutes first aid treatment, refer to the Labor Commission’s Rule R612-100-2(J), at. Once you notify your employer that you have been injured at work, your employer must report the injury to their insurance carrier and the Utah Labor Commission. Your employer and your insurance carrier are required to give you a completed copy of this report along with a copy of Form 100 that explains your rights under the law. If your employer refuses to report the injury, you can report it directly to the Labor Commission or file an Application for Hearing. Your employer can be fined by the Commission for failure to report your injury.
2) Intoxication or Drug-Related Violation
Workers’ compensation is a no-fault system. However, disability compensation (but not medical benefits) may be denied for injuries from alcohol or drug abuse. Also, disability compensation can be reduced by 15% for willful failure to use safety devices or follow safety rules. It is best to consult with an attorney immediately if your workers’ comp claim was denied following a drug test.
3) Idiopathic Condition
Idiopathic: Of unknown cause. Any disease that is of uncertain or unknown origin may be termed idiopathic. If you suffer a heart-attack at work it is likely to not be considered a workplace accident. There are exceptions to this if the idiopathic condition leads to an injury. If your claim has been denied due to an idiopathic condition, it is best to consult with an attorney about the specifics of your case to see if you may still have a valid claim.
4) Pre-existing Condition
In order to prevail on a workers’ compensation claim, the injured worker must show that the injury was caused by the work accident. This is proved by the medical opinions of doctors. If the medical records show that there are no preexisting conditions contributing to the work injury, then any kind of accident, activity, or exposure at work satisfies legal causation. However, if there is a pre-existing condition that contributes to the injury, then the worker must show that the work had enough influence on the injury to make the injury compensable as a workers’ compensation claim. This is referred to as the “Allen Test” after the case that come up with the criteria to determine legal causation for cases involving pre-existing conditions. See, Allen v. Industrial Comm’n, 929. P.2d 15 (Utah 1986). If your workers’ comp claim was denied due to a pre-existing condition, it is best to consult with an attorney about the specifics of your case to see if you may still have a valid claim.
5) Injury Does Not Qualify per Statute
Section 34A-2-401 of the Utah Code provides that “An employee … who is injured and the dependents of each such employee who is killed, by accident arising out of and in the course of the employee’s employment, wherever such injury occurred, if the accident was not purposely self-inflicted, shall be paid: (a) compensation for loss sustained on account of the injury or death; (b) the amount provided in this chapter for: (i) medical, nurse, and hospital services; (ii) medicines; and (iii) in case of death, the amount of funeral expenses.”
In order to be compensated, the employee must show that the injury was “in the course of employment”. This is usually fairly simple – ‘I was at work when I fell off the ladder and broke my arm’. However, sometimes the question of whether the employee was in the course of employment is more difficult to determine – or prove. If your claim has been denied based on whether you were “in the course of employment”, it is best to consult with an attorney about the specifics of your case to see if you may still have a valid claim.
6) No Medical Evidence of Injury
An injured worker must show supporting medical documentation that shows the injury is connected to the worker’s employment. This can be done by a doctor’s medical report. The doctor’s report is one of the most important documents you can have to prove your claim. An injured worker should always get copies of the medical records pertaining to the work injury and review them to make sure the doctor is reporting the injury accurately. If your claim has been denied due to a lack of medical evidence, it is best to consult with an attorney about the specifics of your case to see if you may still have a valid claim.
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