Whether your workplace injury happened suddenly or you have felt the symptoms coming on for a while, you are now facing medical bills, lost wages and perhaps the expense of prolonged treatment. Facing these costs while you are unable to work may create a sense of panic, but you are fortunate that your employer carries workers' compensation insurance to cover those expenses and replace your lost wages.
Workers' compensation is a no-fault system, which means it does not matter if your own actions resulted in your accident or injury. In most cases, you will qualify for benefits. This is to avoid clogging the courts with lawsuits between employees and their bosses for every workplace injury. However, despite the no-fault policies of workers' comp, there are still valid reasons for which the insurer may deny your claim.
Understanding the reasons for denial of benefits
If you receive a letter in the mail informing you that your employer's workers' compensation provider has denied your claim, you will likely have many questions. The answer to your first question – why did they deny my claim – will be in the letter. A few of the most common reasons why an insurer will refuse to pay benefits include the following:
- You did not provide enough evidence that your injury or condition related to your job.
- The injury was self-inflicted.
- Your injuries occurred while you were participating in unsafe activities, such as horseplay on the job.
- You were under the influence of drugs or alcohol at the time of the injury.
- Your injuries occurred while you were in blatant violation of safety protocol.
- You missed the deadline for filing your claim or reporting your injury to your employer.
- You failed to receive medical treatment for your injuries, or you refused to follow through with medical advice.
- You refused to provide further evidence of your injury, such as obtaining a follow-up examination by the insurer's physician.
After receiving your letter of denial, you have options to consider. A denial does not equal a closed case at this point, and you may have grounds to file an appeal. Your appeal will address the factors the insurer names, which may require additional documentation, speaking with witnesses or consulting with your employer.
You may not have another chance after this, and you only have a short window of opportunity to begin the appeals process. For the best chances of a successful workers' compensation claim or appeal, you may find it helpful to consult with an experienced Missouri attorney who has the knowledge and resources to assist you.