There are several reasons why a workers’ compensation claim may fall through. In fact, even those with legitimate claims may find themselves denied the benefits they deserve if they make a mistake in the presentation of their case.
Here’s why your claim might be denied:
1. Disputes over the severity of the workers’ injury.
Your employer or their insurance carrier may claim that your injury is not severe enough to warrant all the benefits you seek to recover. This is a medical issue that will be settled based on treatment records and doctors’ testimony.
2. Disputes over whether the injury was work-related.
The legal term for this is “arising out of employment and occurring during the course of employment,” or AOE/COE. That usually boils down to two things: an event in the workplace, or exposure to something in the work environment. This can arise when an injury or illness takes time to develop, or when the injury occurred outside of the office but while doing some work-related duty.
3. Problems with paperwork or technicalities of the claim.
There are rules which must be followed in filing a workers’ compensation claim. You must notify your employer immediately after being injured — within 30 days of sustaining the injury — and you must fill out a written claim. Failure to meet these and other requirements may lead to a dismissal of your claim.
4. Fault on the part of the worker.
California’s worker compensation laws are no-fault. This means that regardless of who is at fault when the injury occurs, you are entitled to the benefits provided by the workers’ compensation system. However, there are some cases where specific kinds of fault on the part of the worker bar them from making a claim. These include, among others: self-inflicted injuries; being under the influence of drugs or alcohol while sustaining the injury; and violation of company rules/policies.
As you can see, the workers’ compensation system can get fairly complicated and bureaucratic, so it’s best to have the assistance of an expert to ensure the protection of your rights. A workers’ compensation attorney will help you fulfill all the technical requirements properly. A lawyer will also be able to help you explore your options if your claim gets denied.