When Can a Workers Compensation Claim be Denied?

Workers compensation insurance is designed to cover expenses related to a workplace injury, but not all injuries are covered. In some cases, an insurer may deny a workers compensation claim, meaning the employee will have to pay for medical bills related to their injuries.

Excluded Injuries

Sometimes, the nature of an injury can be what causes a workers compensation claim to be denied. Workers compensation only covers injuries that occur at work or in the course of work-related activities.

This generally excludes sudden unrelated illnesses and pre-existing conditions. There are some exceptions when it comes to pre-existing conditions, but they are few and generally rare. For example, say you have a disc in your back. Your job is not physical, allowing you to sit and stand as you need. There is no direct link to your job and your back even if it grows worse, so you would likely not be able to file a workers compensation claim. However, if you can prove that a pre-existing condition has grown worse due to a work-related injury, you may be able to file for workers compensation. You would need solid proof from a medical professional in order for a claim to be approved, however.

Excluded Accidents

In other cases, it is the accident that causes the injury which can lead to a workers compensation claim being denied. Qualifying workplace accidents must happen during the course of work or on work property. If an employee is injured at home after a shift, or at a neighboring business while off work, they will likely not be covered under workers compensation insurance. Other exclusions include:

• Injuries that occur in a fight with another person that the injured employee started
• Injuries that occur while the employee is under the influence of drugs or alcohol
• Injuries that occur while the employee is participating in illegal activities

Other Exclusions

Workers compensation claims can be denied despite the injury or accident qualifying for a claim. Most workers compensation policies have guidelines the employer and employee must follow when filing a claim. If these guidelines are not followed, a claim could be ignored.

For example, many policies have a list of approved healthcare providers along with a time period in which an injured employee must see them. If the employee does not see an approved healthcare provider, or waits more than thirty days to receive medical treatment, a workers compensation claim could be denied.

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