www.howserlaw.com/ (213)377-5513
There are some very common reasons why an insurance company will be denied a claim, and I will explain those in a moment, but what is important, is that you have an attorney who is prepared to fight that denial and prove your case in front of a workers’ compensation judge.
KEEP in mind, if you have received a DENIAL of Worker’s Compensation benefits for any of the following reasons, it absolutely does not mean that you lose your case. What it means is that we need to attack the reasons for the denial and take your case to court and prove liability in front of a judge.
The most common reasons a Worker’s Compensation case is denied are the following:
“THERE IS NO SUBSTANTIAL MEDICAL OR FACTUAL EVIDENCE TO SUPPORT AN INDUSTRIAL INJURY”. (THIS IS THE MOST COMMON)
This is probably the most common reason why an insurance company will deny the claim, and it is very common that insurance carriers will issue THIS DENIAL, even if there IS medical and factual evidence of the injury. In my opinion, this is one of the easier denials to fight, especially when there already evidence of the injury.
The next common insurance denial is:
“THE CLAIM OF INJURY WAS MADE ‘POST-TERMINATION,’ AFTER THE EMPLOYEE RECEIVED NOTICE OF BEING LAID OFF OR TERMINATED.”
Now it is true that the insurance can deny a case if the injury is filed after somebody has been terminated or laid off. However, what the insurance company DOES NOT TELL YOU in that denial, is that there are SEVERAL EXCEPTIONS to this rule including:
1. If you reported your injury to the employer or supervisor before your notice of termination or layoff, or even at the time of being terminated.
2. The employer knew or should have known of the injury prior to the notice of termination or layoff.
3. If there are medical evidence existing prior to the notice of termination or layoff, for example, you had gone to your private doctor for the work-related injury before you were laid off or terminated.
4. If your injury occurred over time. If your injury occurred over time, and you were fired or laid off, there are legal rules that make it difficult for the insurance to defeat this denial. So if you work somewhere for a long time, and your injuries occurred over time, but you were fired or laid off, we can still prove your case and rights to Worker’s Compensation benefits.
The next common insurance denial is:
“THE CLAIM WAS NOT FILED WITHIN ONE YEAR OF THE DATE OF INJURY AND THEREFORE THE CLAIM IS BARRED BY THE STATUTE OF LIMITATIONS.”
It is very rare that an insurance company will win when they deny a case for the reason that “the case was not filed on time.” This defense in California Worker’s Compensation is very difficult to establish because there are many rules that employers and insurance companies do not follow.
Even if your injury or injuries occurred up to 5 years ago, depending on the facts, we may still be able to prove your right to Worker’s Compensation benefits.
Some other reasons Insurance Companies deny Workers Compensation Claims are:
“THE EMPLOYEE DID NOT REPORT AN INJURY THAT OCCURRED ON THE DATE THAT IS ALLEGED.”
Sometimes this can be as silly as the injury date that was filed was opened with the insurance company for the day before or the day after.
“THE INJURY REPORTED WAS ONLY A MINOR INJURY REQUIRING ONLY FIRST AID TREATMENT.”
This is a common denial that we will see with companies that on-site nurses that send the injured worker back to work after being seen by the nurse.
Some other common Denials include:
“THERE IS A DISPUTE ABOUT THE MECHANISM OF INJURY.”
“THE EMPLOYEE FAILED TO COOPERATE WITH AN INVESTIGATION REGARDING THE INJURY.”
“THE EMPLOYEE FAILED TO RESPOND TO A REQUEST FOR A LIST OF DOCTORS HE/SHE HAS SEEN WITHIN THE LAST 10 YEARS.”
THE BOTTOM LINE with all of these insurance denials is the following:
WE WILL STILL FIGHT TO PROVE YOUR RIGHT TO WORKERS COMPENSATION BENEFITS EVEN IF THE INSURANCE COMPANY HAS DENIED YOUR CASE.
If you have received a denial of Worker’s Compensation benefits, it’s is crucial that you have an attorney fighting for your rights who is willing to take your case to trial and prove the insurance carrier is liable for your injuries.
If you have questions about the facts of your Worker’s Compensation claim, or questions about a denial of Worker’s Compensation benefits that you have received from the Workers Comp insurance carrier, please call or text (213)377-5513 and we will be happy to give you an evaluation of your case completely free.
/ @nathanhowser3012