Does Workers’ Comp Need a Reason to Deny a Claim?

In general, a workers' compensation insurance company must have a valid reason to deny a claim. This may include factors such as the injury not being work-related or the employee failing to report the injury in a timely manner. However, it is important to note that each case is unique and there may be specific circumstances that impact whether or not a claim is approved or denied. If you have questions about why your claim was denied, or you are worried that it could be denied but you haven’t filed yet, then you should speak with a workers’ comp attorney right away.

Common Reasons Why Workers’ Comp Claims are Denied

When an employee is injured on the job, they may file a workers' compensation claim to receive benefits such as medical expenses and lost wages. However, not all claims are approved right away. By some estimations from insurance groups, upwards of 25% of all workers’ comp claims will be denied for one reason or another.

Common reasons why a workers' compensation claim may be denied include:

  • Failure to report the injury on time: An injured worker could have 30 days or fewer to report the incident to the employer. If an employee fails to report the injury on time, the claim may be denied.
  • Injury did not occur while on the job: Workers' compensation benefits only cover injuries that occur while an employee is performing work-related duties. If an employee is injured while off-duty or engaged in personal activities, their claim may be denied, or at the least, scrutinized and challenged.
  • Employer disputes the claim: Employers have the right to dispute workers' compensation claims if they believe that the injury did not occur at work or if there is reason to suspect that the employee is filing a fraudulent claim.
  • Injury was caused by drug/alcohol use: If an employee was under the influence of drugs or alcohol at the time of their injury, their claim may be denied.
  • Lack of medical evidence: For a workers' compensation claim to be approved, there must be sufficient medical evidence that supports the existence and severity of the injury. If there is insufficient evidence that the injury actually exists, then the workers’ comp insurance provider will deny the claim or demand to see evidence that clarifies the injury.

The above reasons are all valid for an employer or insurance company to use when denying a workers’ compensation claim. The issue is when a claim is denied for an incorrect reason, or no reason is given at all.

What Should You Do If Your Workers’ Comp Claim is Denied?

If your workers' compensation claim has been denied, it can be a frustrating and overwhelming experience. However, it's important to remember that you have options.

The steps that you should take if your workers' compensation claim is denied:

  • Understand the reason for denial: Your employer or their insurance company should provide a written explanation of why your claim was denied. Review this information carefully to determine the reason for the denial.
  • Consult with an experienced workers' compensation attorney: An attorney who specializes in workers' compensation cases can help you understand your legal rights and options. They can review the details of your case and provide guidance on how to proceed.
  • File an appeal: In Illinois, injured workers have the right to appeal a denied workers' compensation claim, which involves submitting a formal request for review by the Illinois Workers' Compensation Commission (IWCC). An attorney can assist with this process and represent you at any hearings that may be necessary.
  • Provide additional evidence: If your claim was denied due to a lack of medical evidence, you may be able to provide additional documentation from medical professionals to support your case.
  • Keep detailed records: Throughout the appeals process, it's important to keep detailed records of all communication with your employer, their insurance company, and any other parties involved in your case.

Remember, just because your initial claim was denied does not mean that you are not entitled to benefits under Illinois law. By working with an experienced workers' compensation attorney and taking action quickly, you can increase your chances of obtaining the benefits you deserve.

If you have any questions about what to do after your workers’ compensation claim is denied in Chicago or elsewhere in Illinois, call (312) 739-0000 to connect with McHargue & Jones, LLC. Our attorneys can help you discover the right next steps while protecting your rights all the while.