Serious injuries can put your ability to work and earn a living at risk. So when you are injured while at work or performing work duties (even if those duties take you outside the office), your employer is legally responsible for compensating you through their workers’ compensation insurance. That compensation includes money for treatment costs and makes up part of the wages you miss out on while unable to work.
However, filing a workers’ compensation claim is a completely different process than submitting a medical bill to your health insurance, and there are many reasons why a claim could be denied. Unfortunately, many of these reasons are mere technicalities, which can make filing a claim a delicate process that requires a lot of care, attention to detail, and follow up. Without an experienced workers’ compensation attorney on your side at the start, it can be easy for an otherwise valid claim to be denied.
While working to appeal denied claims for our clients, we’ve seen the same reasons for denials over and over again, and have compiled the most common below.
The 5 Most Common Reasons Claims Are Denied
You did not notify your employer of your injury within the required time.
You typically have 90 days after suffering an injury to report it to your employer in South Carolina. This can seem like a lot of time, but many injury victims don’t report their injuries right away, and instead try to work through the pain, because they either think the injury will get better on its own or they are afraid of consequences from their employer.
The longer you wait, the more suspicious the insurance company will be about when and how you were injured. Once those 90 days are up, it will be difficult or impossible to get compensation, even if it turns out you need surgery or another expensive treatment. That’s why it’s best to inform your employer immediately after an injury – on the day of, if you can.
You were not treated by an approved medical provider.
South Carolina law states that if you are being treated for a work-related injury, your employer has the right to select the doctor you see. If you see your own doctor, there is no guarantee your employer will agree to pay the bill or can be forced to pay the bill. Usually the only exception is if you needed immediate emergency treatment and there wasn’t time to get approval from your employer beforehand.
You did not get treatment at all.
Workers’ compensation provides money for medical expenses and two-thirds of your weekly wage until you are able to work again. However, your employer will likely refuse to compensate you for your lost wages if you can’t prove the injury that temporarily disabled you exists. For that, you’ll need a diagnosis from a medical doctor—and that means getting a full check-up and treatment.
You were under the influence of drugs or alcohol at the time of the injury.
If your employer believes you were injured because you were drunk on the job, or believes you were under the influence of illegal drugs, they have the right to request you be tested. If your test comes up positive, your claim will generally be denied.
Your employer disputes your injury is work-related.
Although you don’t need to prove that you were injured because your employer was negligent in order to get workers’ compensation benefits – you can even still receive benefits if your injury was your own fault – you still need to be able to prove your injury was work-related.
If there were no witnesses to the injury, your employer may try to claim you were injured off-the-clock and that you’re passing it off as a work injury. This scenario is especially likely if you submit your claim just before or after a weekend or holiday. They may also try to argue your injury wasn’t work-related, even if it happened in the office. For example, they may argue this if someone was injured while goofing around on a coffee break, since they were not “working” at the time.
We Help Appeal Denied Worker’s Comp Claims
There are so many reasons and ways a workers’ compensation claim can be denied. If you are already dealing with the stress of trying to pay your living expenses until you can work again on top of the pain of injury, the frustration can be too much to handle.
Thankfully, even a denial isn’t final. We work with injured workers who have yet to file a claim as well as with workers who have already been denied in order to get their claims appealed.