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Reasons insurers deny workers’ compensation claims

Employers have workers’ compensation insurance to protect both themselves and their workers when accidents resulting in injury or illness happen. Benefits cover medical bills, lost wages from missed work, rehabilitation and other associated costs and can greatly relieve the financial burden of getting hurt.

However, it is not uncommon for insurers to deny workers’ compensation claims. They may do so for various reasons.

Reporting delay

One of the primary reasons for a denied claim is failure to report the injury to an employer promptly. Delaying reporting causes complications because it raises questions about the legitimacy of the claim. It also delays the employer, who must go through certain reporting processes by a certain deadline as well.

Medical discrepancies

Accurate and thorough medical documentation is important for a successful workers’ compensation claim. Denials often stem from inconsistencies or gaps in medical records. Incomplete or unclear information about the injury, treatment or link between the injury and the workplace can give rise to skepticism.

Pre-existing conditions

When there are pre-existing conditions, the lines between them and new injuries may blur. It is not uncommon for insurers to deny a claim on the basis that they believe an injury to be a pre-existing condition or due to one. Note that if a workplace incident or condition leads to the exacerbation of an existing condition, a worker may still be eligible for compensation for the worsening of the injury or illness.

According to the U.S. Bureau of Labor Statistics, there were almost three million reported nonfatal injuries and illnesses in the private industry in 2022. Workers’ compensation is a valuable aid in such cases, so a rejection can feel discouraging. However, an initial, second or even subsequent denial is not the end. Workers can appeal rejections more than once.