Why Policy Providers Deny Workers’ Comp Insurance Claims

Accidents and injuries in the workplace are sometimes inevitable and expensive. If an employee gets injured in a workplace accident, they are entitled to workers’ comp.

Workers’ compensation covers any medical expenses that go toward treating the injury. It also covers about two-thirds of the employee’s weekly wages, which they receive for the period they’re out of a job.

In the U.S., every business with at least four employees must have workers comp. It protects the employer and employees as well. Employees get covered in the event of an accident irrespective of who’s at fault. They get insured for medical expenses and wages whether or not they caused the accident.

On the other hand, the employer gets insured if an employee decides to file a suit. Ordinarily, receiving workers’ comp payments means that an employee will not sue their employer for the accident. However, employees can file a lawsuit against their employers if they believe that the accident happened due to their gross negligence.

How Workers Comp Settlement Process Works

The workers’ comp settlement process can be easy or tedious depending on the employer and employee. They both have roles to play to ensure that the process goes smoothly.

In 2019, the U.S Bureau of Labour Statistics recorded nearly 2.8 million nonfatal workplace injuries. Annually, companies in the U.S spend about $62 billion on lost time related to workplace injuries.

An employee is to report to their employee if they get injured in the workplace. Depending on the severity of the injury, the employee can get medical attention immediately or wait for their employer.

The employer then sends the person to receive treatment if they haven’t. Then the employer investigates the injury and takes statements from witnesses. After investigation, the employer can file an insurance claim from their policy provider.

It is the responsibility of employers to file claims from their policy providers. The policy providers can accept or deny the claims. If the policy provider agrees with the claims, they make payments covering medical expenses and lost wages.

Why Do Policy Providers Deny Insurance Claims?

After an employer has filed for workers comp claims, the policyholder still investigates the accident. During the investigation, certain situations may cause the insurance provider to deny such requests.

Here are some reasons for denying claims:

  • If the injury was due to fighting or horseplay in the workplace
  • Self-inflicted injury
  • The accident occurred during an employee’s work commute
  • If the accident happened while the employee was under the influence of alcohol or drugs
  • Violation of company rules or committing a crime

The workers’ comp insurance provider works with the investigation and medical report to make their decision.

Why Does Workers’ Comp Claims End in Litigation?

After an insurer has agreed to pay for an employer’s claims, an employee can decline the offer. If the employee chooses to reject the amount offered, they take the insurer to court. This situation only arises when the employee feels that the compensation offered is unfair.

The employee works with their workers’ comp attorney to work out what they believe is fair compensation. Here are few things that they consider before going to court:

  • Lost wages and potential loss of earning in the future
  • The validity of their claims (considering factors that could diminish the amount they will receive)
  • Workers comp policy of the state where the injury occurred
  • Disability payments
  • Cost of retraining to perform the old job if it’s the necessary or new job
  • Medical expenses already incurred and future medical costs for the same injury
  • Legal fees

If the insurer and employee cannot agree on what they consider fair, they will have to go to court. The court will decide on a settlement that both parties will have to accept or appeal. Except in cases where the employee is suing the employer for negligence, the workers’ comp case is usually between the employee and the insurer.

However, the employer should provide all the necessary information the court may need and support their employee. After arriving at a settlement both parties agree on, the payment commences. It can be a lump sum or a structured fee paid over a certain period.

Do I Need a Workers Comp Attorney?

The simple answer would be NO. But, we know that filing for a workers comp claim is not a walk in the park. It can be traumatizing when you or your loved one gets involved in a workplace accident. You will need an experienced work comp attorney who will advise you and ensure you make decisions that work for your best interest. Contact us today at Pinder Plotkin LLC for a free consultation.

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