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Ochoa & Calderon

Why Workers’ Comp Claims Get Denied

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California law requires all employers to carry workers’ compensation insurance for the benefit of their employees. Employers, through their workers’ comp insurance providers, must pay out benefits to injured workers so long as they were injured on the job. There are a number of justifications an insurer or employer may give to deny coverage for a claim, however. Their reasons may be legitimate, or they may be unscrupulous stall tactics intended in bad faith to discourage an employee from seeking full coverage. Below, we discuss the proper justifications to a claim denial for workers’ comp benefits. Just because your workers’ comp claim was denied, however, does not mean you are not due benefits. Review the reasons workers’ comp claims may be denied below, and call a seasoned Riverside workers’ comp benefits attorney for help filing your claim and appealing an improper claim denial.

Injury Not Work-Related

Workers’ compensation exclusively covers work-related injuries. That means that it covers injuries that occur either at the workplace or while off-site, provided the employee is engaged in job-related duties at the time. When an employee is injured at the workplace, such as in a slip-and-fall in the office hallway or a construction accident on a worksite, coverage is clear. If the injury happened off-site, however, proving the injury was work-related can be more of a challenge.

Employees who are injured in a car crash on their lunch break, for example, might not be covered, because travel to and from the office is often not considered work travel. Injury in a car accident while performing a delivery for work, on the other hand, would be covered. Injuries on work trips likewise can be difficult to analyze.

Additionally, your workers’ comp insurer may try to claim that your injury was not actually caused by work-related tasks. If you suffer a repetitive stress injury like carpal tunnel or tennis elbow, for example, you are entitled to coverage so long as the condition was caused by performing job tasks. The insurer might try to claim you sustained the injury through recreational and other non-work activities, and deny your claim on that basis. Talk to your workers’ comp attorney about how best to support your workers’ comp claim.

Exception to Coverage

Workers’ comp covers nearly every workplace injury, but not all. There are certain exceptions to coverage. A workers’ comp insurer can legitimately deny coverage to a worker if:

  • The employee was intoxicated at the time of the incident, and that intoxication caused or contributed to the injury
  • The employee deliberately injured themselves
  • The employee was engaged in criminal activity at the time of the incident, such as if they were injured after physically assaulting another employee

Failure to Follow Proper Procedure

To collect workers’ comp benefits, the employee must take appropriate steps after their injury, and they must do so within set time frames. First, the employee must notify the employer of their injury, typically within 30 days of sustaining the injury. Injuries sustained over time, such as repetitive stress, can complicate the necessary time frame. The employee must then fill out the appropriate forms given by their employer, explaining the nature and circumstances of the injury and the benefits needed.

Additionally, workers must actually obtain medical treatment after a workplace injury in order to obtain benefits. Refusing to see a doctor or missing scheduled appointments can be grounds for the workers’ comp insurance provider to deny benefits and claim the worker was not truly injured. Insufficient medical evidence is a common reason for benefits to be denied. See a doctor as soon as possible after your work-related accident, and make sure to attend all future appointments. Workers’ comp will cover the cost, and missing those appointments can only lead to the risk of benefits being denied.

If you or someone you love has been seriously hurt on the job in California, get help seeking the workers’ compensation benefits you’re owed by contacting the Riverside offices of Ochoa & Calderon for a consultation on your case.

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