Reasons Your Workers’ Comp Claim May Be Denied, and What to Do About It

Workers’ compensation is designed to be a no-fault system, providing benefits to employees injured or made ill by their work regardless of who is to blame for an accident. However, there are several common reasons why workers’ compensation claims are denied, creating potential obstacles to receiving these benefits.

The following are the most frequent reasons for workers’ compensation claim denial:

• Failure to promptly notify the employer of the injury — Workers are required to report injuries within 90 days. Missing this deadline can result in an automatic denial of the right to obtain benefits. 
• Missing deadlines for necessary filings — There are specific time limits for submitting workers’ compensation claims and other documents.
• The injury or illness is deemed not work-related —This can occur if the injury results from a pre-existing condition rather than a work incident, or if the accident happened off the clock, such as during the commute to or from work or during breaks. Additionally, injuries resulting from horseplay or hobbies, even if they occur at the workplace, may not be covered.
• The injury or illness was due to intoxication or the use of illegal drugs —Workers’ compensation policies generally exclude coverage for injuries sustained while the employee was under the influence, as this is considered a violation of workplace safety protocols.
• The employee did not seek medical treatment — Medical documentation is essential for substantiating a claim, and failing to get treated can suggest that the injury was not serious or work-related. Furthermore, accessing out-of-network medical care without prior authorization can lead to denial, as most workers’ compensation plans have a network of approved providers.
• The medical condition is not covered under workers’ compensation insurance — These exclusions vary but examples are certain soft-tissue injuries and conditions like stress or psychiatric disorders.

If a workers’ compensation claim is denied, there are remedies available. The first step is to review the denial notice, which should explain the reasons. You then have the option to file either a formal or informal appeal with the New Jersey Division of Workers’ Compensation. A formal appeal leads to a hearing before a judge, at which you will have the opportunity to testify and present evidence in court. An informal claim results in a judge reviewing your claim and making recommendations about how the denial might be remedied.

Engaging an experienced workers’ compensation attorney can be essential in putting you on the right appeal path and heading up the process. An attorney can help gather necessary medical evidence, ensure all filings are completed correctly and on time and represent you at hearings. They can also negotiate settlements to secure the benefits you deserve.

Kevin T. Kutyla, Esq. in Succasunna helps injured employees throughout New Jersey access the benefits they deserve. Call 973-940-8970 or contact me online to schedule an appointment.