The Top 5 Reasons Workers' Compensation is Denied

Your employer and their insurance company both save money when valid claims are denied. Our Vermont workers' compensation attorneys share five common reasons that insurance companies give for denying a claim.

The Top 5 Reasons Workers' Compensation is Denied

Vermont’s workers’ compensation laws are meant to provide a fair and predictable system to help employees and employers deal with workplace injuries.

It's a “no-fault” system where injured workers can get compensation for lost wages and medical expenses after a workplace accident, and employers get protection from costly lawsuits. But this win-win situation does not always play out fairly in practice, such as when the employer’s insurance carrier denies a legitimate claim.

Insurance companies use many tactics to deny benefits when employees are injured doing what is asked of them in their jobs. It is important for Vermont workers to be aware of the common reasons for denial, along with what to do if you get injured at work.

Who Benefits When Your Claim is Denied?

Your employer and insurance companies both save money when valid claims are denied. Your employer wins because their insurance rate doesn’t go up if a case is denied, and the insurance company wins because they don’t have to pay you any benefits.

Reasons For Denying Your Claim

In our experience, there are five common reasons that insurance companies give for denying a workers’ compensation claim.

Reason #1: Your Injury Was Not Related To Your Work

This is one of the easiest reasons for the insurance company to deny your claim. If they can find a way to show that your injury is not work-related, they will because it means that they can deny the claim. Some examples that we have seen are:

  • No one witnessed your injury, therefore there is no proof that it happened at work.
  • Your non-work hobby or sport caused the injury.
  • You have a pre-existing condition that caused the injury.
  • You did not report your injury to your employer when it happened.

These are some of the most common “workarounds” used by insurance companies to deny that an individual’s claim was work-related. If your claim has been denied for any of these reasons, contact Biggam Fox Skinner today. We would love the opportunity to have you come in for a free case evaluation to show you how we can help.

Reason #2: You Didn’t Notify Your Employer in Time

Notifying your employer of your injury as soon as it happens is very important for strengthening your workers’ compensation case. If you wait, there are a few things that may happen:

  • Your employer or their insurance company may try to say that you weren’t actually injured at work because if you were, you would have reported it sooner.
  • The insurance company may claim that the injury was caused by a pre-existing condition.

Reason #3: Your Medical Records Do Not Support Your Injury Claim

To build a successful workers’ compensation case, you need to provide supporting medical evidence. Filing a workers’ compensation claim without the medical proof to back it up will give the insurance company a reason to deny your claim. That’s why one of the first things to do following a workplace injury should be to see a doctor and get your injury documented and treated.

Make sure to document ALL your injuries and symptoms, even if they seem insignificant or unrelated at the time. Sometimes things can worsen over time or flare up later but if they are in your medical notes it is harder for the insurance company to claim they are new or not related. Understand that everything you tell your medical providers about the injury may be seen by the insurance company, so make sure you are consistent and thorough.

Reason #4: You Did Not Sign Medical Authorization Forms When Asked

The insurer assigned to your case will want to review the medical records and bills for your injury and treatment. This is very important as it can help to establish a link between your injury and your workplace.

You must sign the required authorization (a Form 7) if asked. If you don’t, it gives the insurance company a reason to deny your claim. You don’t have to forfeit your privacy by providing your entire medical file to the insurer. You will only need to provide them with access to your work injury treatment records. It is also important to note that the insurer has a legal responsibility to investigate your claim, meaning you should not withhold relevant information without cause.

Reason #5: A Pre-Existing Condition Caused the Injury

This is perhaps one of the most common tactics that insurance companies will use to deny a claim. They will try to state that the injury you sustained was not new, and was, in fact, something that had been going on long before the incident.

Regardless of your medical history, you are entitled to get benefits for a new work injury if it worsens your underlying condition. For example, a nurse who has a history of lower back problems may injure his back by turning a patient over. Although the nurse had a pre-existing condition, the new injury should be covered if there is medical evidence that his work made the pre-existing condition worse and that links his new injury to his job.

This is where hiring the right Vermont workers’ compensation attorney comes into play. An experienced attorney, like those at BFS, will be able to link your injury back to your workplace to help you receive the maximum compensation you deserve. Don’t make the same mistake many others have made. If your claim was denied on the basis that a pre-existing condition caused the injury, and you are worse off because of what happened at work, don’t take no for an answer.

If your Vermont workers’ compensation claim was denied for any reason, call Biggam Fox Skinner at (802) 445-9141 today to schedule a free consultation to discuss your case.

"Not only a professional relationship; a friendship was created. Your guidance through the process of my injury and recovery was extremely important. Thank you Kelly, Tasha, and team!"
- Dwayne, South Burlington, VT