Why Do Insurance Companies Often Deny Claim for Work Related Injuries?

  • May 17, 2021

If insurance companies made it easy to qualify for workers’ compensation coverage, then not many employers would buy the offered policy. No employer wants to make it easy for any worker to fake an injury, and then receive money, while staying home.  

What criterion must be met, in order for an injured worker to receive workers’ comp benefits?

The person that has applied for those benefits had to be employed when he or she got hurt. The same individual had to be doing something for his or her boss. The person that has been injured while on the job had to be working for an employer that had purchased workers’ comp insurance.  

What special circumstances might lead to denial of a claim, even if the above criterion appears to have been met?

A provider of workers’ comp insurance will not provide coverage to someone that has exhibited some form of misbehavior, while performing an assigned task at his or her workplace. The act of consuming alcohol while on the job would qualify as a form of misbehavior.

Similarly, the act of using drugs, while performing a job-related task, would be evidence of misbehavior. Even horseplay carried out at work, if it has caused harm to the playful participant in that same act could become grounds for denial of insurance benefits.

What happens if an employee with a pre-existing condition were to get hurt at work?

If the employee’s performance of a work-related task had managed to aggravate the pre-existing condition, then the injured worker would qualify for benefits from the insurance company. Still, the insurance company might elect to provide a reduced level of coverage.  

In addition, the personal injury lawyer in Normal knows that legitimacy of the injured employee’s claim might be questioned. Hence that same worker might be asked to attend an independent medical examination (IME). In fact, the insurance company does not have to accept the opinion of a single medical examiner. It has the right to schedule a second IME for the person that has submitted a request for workers’ comp coverage.  

Someone with a genuine injury would find it much harder to go after a second opinion, if he or she were declared well by the doctor that had conducted an IME. Of course, such a declaration might please the examined employee’s boss, but it could be disquieting news for those that worked in the company’s Human Resources Department.

How a deadline might play a role in denial of coverage?

An injured worker must report that injury to his or her employer within 30 days of having suffered some manner of harm, while at work. A worker’s failure to meet that deadline could become grounds for denial of requested insurance coverage.