Why Do Workers’ Comp Claims Get Denied?

After suffering the pain of a workplace injury, it can be frustrating to be met with denial after filing a workers’ comp claim. Sadly, many hardworking California employees experience get rejected for workers’ comp benefits on a regular basis.

These injustices can leave workers stranded without the financial means or resources to cover their medical bills, loss of wages, and other expenses incurred in the accident. While a rejected workers’ comp claim can feel like a dead end, rest assured that California companies can and should be held accountable for their actions—especially if their negligence resulted in serious injury to employees.

With the help of a qualified workers’ comp attorney, it’s possible to successfully appeal the denial and recover the benefits you rightfully deserved from the beginning. Keep reading to learn why workers’ comp claims get denied and what steps employees can take to receive the benefits they deserve.

Understanding Workers’ Compensation in California

When appealing a denied workers’ comp claim, it can be exceedingly helpful for employees to understand why their claim was denied in the first place. This can offer needed insight, such as potential filing errors or the need for additional or stronger evidence.

Even the simple realization that there is no case to pursue can prevent workers from wasting copious time and resources on claims that will inevitably be denied again. Although workers’ compensation is considered a no-fault system, there are some instances where an injured employee may be ineligible for workers’ comp benefits.

While there are some exceptions to the following rules, common examples of ineligible injuries include:

• Injuries sustained while commuting to or from work. Injuries sustained during an employee’s morning or evening commute generally aren’t covered by workers’ comp.
• Injuries sustained while under the influence of drugs or alcohol. If the employee was intoxicated or drugged when the incident occurred, they may be ineligible for workers’ comp benefits.
• Injuries sustained during a recreational activity. Certain company-hosted events, such as teambuilding and social gatherings, may be ineligible for workers’ comp. Common examples include happy hours, picnics, and holiday parties.
• Workplace disputes. Behaviors that fall outside the scope of employment are generally ineligible for workers’ comp. Examples include horseplay or reckless behavior in the office, practical jokes, and fights with colleagues or coworkers.

Top 3 Reasons Why Workers’ Comp Claims Get Denied

Workers' comp denials can create significant hardships for injured employees, many of whom already feel like the odds are stacked against them. Even when involved parties act in good faith, it’s still possible for a workers’ comp claim to get denied, making it all the more important for rejected applicants to seek counsel from a knowledgeable workers’ comp attorney.

The potential reasons behind a denied workers' comp claim vary from situation to situation, but there are some common themes. Insufficient evidence, inaccurate information, and incomplete documentation are some of the factors that can result in an application getting denied.

Consider these top 3 reasons why workers’ comp claims get denied in California:

1. Insufficient Evidence

Insufficient evidence is one of the most common reasons why a workers' comp claim gets denied. If an injured employee cannot provide adequate proof that an accident occurred in the workplace as a direct result of an employment-related incident, then the workers’ comp claim will likely be denied. This is especially true if there were no witnesses to the accident and no medical documents to support it.

Insurance companies may require more evidence than what was initially provided to make a determination. They may also disagree with included evidence, such as medical documentation or diagnoses. As you can imagine, these issues can impose significant stress on employees, especially those with severe injuries requiring extensive medical care or continued treatment.

Workers may be forced to pay for these services out-of-pocket until the workers’ comp dispute gets resolved—if it gets resolved at all. To ensure their claims are approved and they receive the compensation they deserve, employees must provide as much proof of their injury as possible. Examples include:

• Police reports detailing when and how the incident happened
• Photographs depicting any property damage or physical injuries sustained in the accident
• Medical documents verifying the extent of their injuries and any treatments received
• Witness statements from those who saw what happened during the accident
• Affidavits signed by employers acknowledging what happened leading up to and after the incident occurred

Injured workers who were denied workers’ comp benefits are strongly encouraged to consult with a trusted workers’ comp attorney before submitting additional evidence or appealing the denied claim, as a legal advocate can review all evidence and documentation with a practiced legal eye to ensure it meets the standard for sufficiency and relevance.

2. Application & Procedural Errors

In addition to inadequate evidence, procedural errors and application mistakes can also lead to the denial of workers’ comp claims. If an employee fails to adhere to the proper filing protocol, such as not submitting their claim on time or failing to provide sufficient proof of their injury and related treatments, their claim will likely be denied.

The state of California upholds strict rules and regulations that applicants must comply with when filing for workers’ comp benefits. Even the slightest mistake on a required form can result in an immediate rejection.

Being denied on the basis of a small, unknown procedural error can leave many employees feeling powerless. Not only can it further delay the process to receive the care injured workers require to support themselves and their families during recovery, but it can also result in extensive litigation during the appeal—all while the employee’s financial security hangs in the balance.

Below are some common procedural errors that employees make when appealing or filing a workers’ comp claim:

• Not including required documentation
• Providing incorrect dates or locations
• Leaving sections blank on required forms
• Listing inaccurate or outdated contact information

It’s vital for employees to ensure that all paperwork is filled out correctly and in its entirety to avoid getting their workers’ comp claim denied.

3. Failure to Seek Medical Care

Employees should seek medical attention immediately following any type of workplace incident if they wish to get approved for workers’ comp benefits. Failure to seek medical care after a workplace injury can result in a workers' comp claim getting denied for several reasons. Without an official diagnosis of the injury, it can be difficult to prove that the injury is work-related. Without this proof, insurers may deny the claim as they will lack confidence in the validity of the case.

Additionally, medical documentation is essential for proving both the cause and extent of the injury. For example, if an employee fails to get proper treatment or sufficient rest after a workplace incident, then their condition could worsen over time due to neglect. This would make it harder to accurately diagnose and treat the injury effectively, which would make it difficult to prove that the employee's current condition is related to their workplace accident to receive full benefits.

Lastly, by not seeking medical attention after a workplace injury, employees risk having their claims rejected on technical grounds. Insurance companies typically have strict deadlines for filing workers' compensation claims and usually require timely medical documentation of injuries to approve claims. If an employee fails to meet these deadlines or provide sufficient evidence of their injuries, such as a medical evaluation or MRI scan results, their claim can be denied.

Protecting the Rights of Hardworking Employees in CA

Our compassionate team at Alvandi Law Group has extensive experience representing injured California employees in a range of workers’ compensation cases, from machine malfunctions to work vehicle accidents. If your employer is giving you the run-around after filing for workers’ comp benefits, you deserve experienced legal representation to recover the damages you rightfully deserve.

Our accomplished attorneys are solely dedicated to assisting wronged employees with workers’ compensation cases. With over 75 combined years of legal experience and over a billion dollars recovered on behalf of our clients, our compassionate legal advocates are well-equipped to represent your best interests in court. If you’ve suffered an injury in the workplace, turn to a law firm you can trust to protect your employee rights.

If you were injured in the workplace, our firm can fight for the maximum workers’ comp benefits you deserve. Call (800) 980-6905 or contact us online to schedule a free consultation.