Employers must report injuries to their workers’ compensation insurance carrier, but there may be instances where the employer contests the claim before it reaches the insurance company. To help clarify, employers cannot legally deny a workers’ compensation claim. However, in some cases, they may dispute the claim, asserting that the injury is not work-related, did not occur within the course and scope of employment, or for other reasons.
Then, the insurance company can deny the claim if the employer states that the injury did not happen the way the employee reported.
The employer’s workers’ compensation insurance company is responsible for evaluating and deciding on claims. After receiving notice of a workplace injury, the insurance company will investigate the claim. If the insurer believes the claim is invalid, they may deny it. Reasons for denial can include disputes over the cause of the injury, the severity of the condition, whether it is work-related, or issues with documentation.
The insurance company is only interested in protecting its bottom line — not paying workers’ compensation claims — so they may dispute the benefits immediately and make the injured worker prove their injuries are work-related and as severe as they described.
Here, we describe some common reasons for workers’ compensation denials in California.
What are the Most Common Reasons Insurers Deny California Workers’ Compensation Claims?
One of the most common reasons for workers’ compensation denials is failing to report the injury promptly. Notifying your employer as soon as possible after the injury occurs is crucial. Delays in reporting may raise questions about the validity of the claim.
Other reasons the insurance company may dispute your California workers’ compensation claim may include:
- Dispute Over the Where the Injury Occurred
If your employer disputes that your injury or illness is work-related, the insurance company may deny your claim. Providing clear evidence linking the injury or illness to your work is essential.
- Pre-Existing Conditions
Insurance companies may dispute claims if they believe your injury is related to a pre-existing condition rather than a new workplace incident. However, you may still be eligible for benefits if a work-related incident exacerbates a pre-existing condition.
- Failure to Seek Medical Treatment
If you delay seeking medical treatment or fail to follow prescribed medical advice, your employer may question your injury’s severity or commitment to recovery.
Inadequate or inconsistent medical evidence can lead to claim denials. Ensure that you seek prompt and appropriate medical attention and provide comprehensive documentation of your injuries, treatment, and how they relate to your job.
- Intoxication or Substance Abuse
If your injury resulted from being under the influence of drugs or alcohol, your claim may be denied. Employers may conduct drug tests after an incident, and positive results can impact your eligibility for benefits.
- Independent Medical Examination (IME) Discrepancies
If you undergo an independent medical examination as part of the claims process and the results differ significantly from your treating physician’s assessments, your claim may be contested.
If your workers’ compensation claim is denied, you have the right to appeal the decision, and we can help. Contact our skilled California workers’ compensation attorneys, who can help you understand the reasons for the denial and guide you through the appeals process to seek the benefits you deserve.
We have six physical offices in Bakersfield, Fresno, Santa Barbara, Santa Maria, Ventura, and Visalia, and our top-tier technologies provide a virtual reach to serve clients throughout California. We offer free in-person, telephone, and virtual consultations to offer straightforward legal advice for your unique needs.
Contact us today to learn how we can help.