Why might my employer deny my workers’ compensation claim?

On Behalf of | May 23, 2022 | Workers' Compensation |

If you get hurt on the job or suffer a work-related injury, the odds are you deserve workers’ compensation. However, there’s still a good chance you’ll face some challenges from your employer or, more appropriately, your employer’s insurance company.

Insurance companies love to collect premiums, but they don’t much love to pay for claims. Workers’ compensation is the law in North Carolina, and the law presumes that employers and employees all agree to its terms. Still, there are various loopholes. If the insurance company can argue that your claim falls into one of these loopholes, it won’t have to pay as much.

11 tactics insurance companies use to deny and reduce workers’ compensation claims

The North Carolina Workers’ Compensation Act is a long, detailed piece of legislation. If you look at it as a PDF, it runs 85 pages, and those pages are full of specific definitions, detailed processes, allowances and exceptions. You can expect that any insurance company that deal with North Carolina workers’ compensation will have a team of attorneys who pore over every detail.

This means the insurance company may find any number of ways to challenge, deny or minimize your claim. Some of the more common arguments include:

  • Saying you are not a covered employee

While most employees are covered, most independent contractors are not. There are also exclusions for certain industries, and the law openly states that truck drivers may or may not be covered employees. Their status often depends on how their duties compare to the legal definition of an employee, versus that of a contractor.

  • Claiming your injury is not work-related

If you suffer a break or strain due to a collision at work, your case is likely open and shut. However, back injuries, repetitive motion injuries and work-related diseases often demand more evidence. You may need to prove the injury or disease resulted from your work duties and not as the result of a prior condition.

  • Arguing that you were drunk or under the influence of some other intoxicant

When alcohol or drugs contribute to work injuries, the insurance companies are excused, unless your employer provided the alcohol. However, the insurer must also argue that you were “under the influence” enough to “lose the normal control” of your body or thinking.

  • Claiming your injury resulted from a willful action

Workers who deliberately injure themselves do not qualify for workers’ compensation.

  • Claiming you willfully chose not to use safety gear, follow the law or follow safety rules your employer had clearly communicated

These actions do not necessarily disqualify you from receiving workers’ compensation, but they can reduce the amount you receive. Deliberately choosing not to follow the safety rules or use proper safety equipment can shave 10% off your compensation. On the other hand, you can get more if your employer’s decision not to comply with statutory regulations led to your injury. Workers’ compensation law does not allow you to sue your employer, but you can increase your reward by up to 10%.

  • Arguing that you lied about your physical condition to get hired

If the insurance company can find proof that you were willfully dishonest about your physical condition, it may be able to deny your claim. To do this, the insurance company needs to prove that you willfully misrepresented your physical condition. That information must then influence your employer’s decision to hire you. Finally, there must be a connection between the misrepresentation and your work injury or occupational disease.

  • Claiming you aren’t injured or that you have recovered

You’ve probably heard that you want comprehensive medical records when you file a workers’ compensation claim. That’s true, and it’s largely because insurance companies often claim that workers’ injuries don’t actually prevent them from working. In fact, there are horror stories about workers who saw their workers’ compensation dry up because insurance companies hired private detectives to snap pictures of them lifting objects or walking without supports.

  • Pointing out that you refused to submit to an independent medical examination

Employees aren’t the only ones who gain some rights from the Workers’ Compensation Act. The law also grants employers the right to have you submit to independent medical examinations. This allows them to get medical opinions from doctors of their choice. Your employer is supposed to request the exams at “reasonable times and places,” and if you refuse, you forfeit your workers’ compensation. Of course, there’s a risk that your employer could find a doctor who downplays your condition. That’s why it’s important to note that you also have the right to have your own physician present.

  • Pointing out that you have failed to follow your treatment plan

If your injury keeps you out of work for any length of time, you’ll likely receive a treatment plan. You want to follow this plan carefully. It’s wise to make sure your doctor provides clear documentation after each appointment.

  • Showing that you missed steps in your workers’ compensation claim

You have deadlines to meet when you file for workers’ compensation, and you have steps you need to follow. If you miss your deadlines or don’t report your injury to your employer, you could lose out on workers’ compensation.

  • Offering you a settlement

Your employer and the insurance company can legally offer you a settlement for your workers’ compensation claim. They may do this when your injury or illness is serious. For example, if you develop asbestosis or silicosis after years of mining, your employer might prefer to settle all at once, rather than track a series of payments. You might also receive a settlement offer if your injury leads to permanent disfigurement or disability. However, it’s important to understand whether the settlement is fair. Settling for an amount that’s too low, even if it looks like it covers everything, might prevent you from getting everything you deserve.

What you can do to make sure you win fair compensation

Naturally, you don’t want to see your claim challenged or denied. So, what can you do? The answer is to do things right the first time.

There are several steps you should be sure to follow:

  • Report your injury to your employer.
  • Seek medical treatment.
  • Work with an experienced workers’ compensation attorney. This will help you avoid making mistakes that hurt your claim in the following steps.
  • Inform your physician that your injury is work-related. This allows them to bill appropriately, and you want to get the documentation.
  • Report your work-related injury to the appropriate manager or personnel at your work.
  • Within 30 days of the accident, provide your employer a simple written notice. This should include the date of the injury and a brief description.
  • Stick with your physician’s treatment plan.

If you do these things and keep good record of your physician’s notes, you should have a solid basis for your claim. It’s possible the insurance company may deny it anyway, but you can appeal, if necessary.

What if I don’t understand the process?

It’s easy to feel overwhelmed by all the rules and information connected to workers’ compensation claims. Few workers spend any time reviewing these rules until they suddenly matter a great deal. At that point, 85 pages of legal terminology can be a lot to process. That’s why it’s often wise to work with a guide, and the workers’ compensation attorneys at Hunter & Everage are here to help.

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