Employers’ insurance carriers that provide Workers’ Compensation coverage are balancing many competing motivations. Providing helpful benefits to an injured employee is not always the primary focus. Often the decision-makers within the insurance agency who determine the legitimacy of injury claims may find that saving the cost of covering a claim is more of a priority than paying out to a claimant who has not made a completely compelling case. This may lead those evaluating the claim to find that the injury does not meet the standard that would qualify for coverage under the company’s Workers’ Compensation program.
Thankfully, workers who have been denied coverage for what has been deemed a non-work-related incident do have the option for appealing the denial of their claim.
What Might Cause a Denial on the Basis that the Injury Was Not Work Related?
While there are many reasons that may result in a denial of Workers’ Compensation benefits, one common reason is that the injury did not come about because of job-related duties or actions. This may happen because the report may have used unclear language or may have failed to explain the link to work causes.
In other cases, the investigators may have been unable to find corroborating evidence that connected the injury to the job. In these and other cases, it is not only possible, but also essential, that an injured worker appeal the decision and further pursue the benefits they are due.
What Must Be Proved to Secure Workers’ Compensation Benefits?
For a worker to show that they are eligible to collect Workers’ Compensation benefits, two things must be proved. First, it must be shown that the worker’s injury occurred while the employee was engaged in performing their job; and second, it must be clear that the injury was linked to actions related to employment.
Why Would a Workers’ Compensation Claim Be Denied?
Although denial of a claim is not the last word when it comes to Workers’ Compensation benefits, some circumstances, which occur often in claims that go on to succeed, that may result in an initial denial include claims for accidents that happen to:
- An employee who was not on the work premises at the time of their work accident.
- An employee who failed to include in the initial incident report how the accident was linked to work duties.
- An employee who experienced a resurgence of a prior condition that may have plagued them in the past.
- An employee suffering from a repetitive strain injury that may have been aggravated by work duties as well as actions performed outside of work.
What if My Work Incident Exacerbated an Existing Condition or Worsened a Prior Injury?
Regulations by the Occupational Safety and Health Administration (OSHA) include Occupational Injury and Illness Recording and Reporting Requirements that state that an injury or illness must be considered work related if an event or exposure in the work environment caused or contributed to the injury or illness or significantly aggravated a pre-existing injury or illness.
This assessment could not only link a chronic injury to work-related actions or exposures, but also establish that an off-the-clock injury could be based on work tasks or job duties that set the scene for the harm.
What Workplace Injuries Are More Likely to Be Denied for Good Cause?
Employees who become injured at work while they are engaged in horseplay or other irresponsible behavior unrelated to their job are likely to be denied benefits for the injuries that result.
Workers who become injured while they are commuting to or from their place of work are also unlikely to be successful in a claim for Workers’ Compensation benefits.
Likewise, employees who get hurt on their lunch break, unless they are engaged in work duties such as possibly picking up lunch for their boss, are likely to be denied benefits for any injury suffered during their break. Accidents that happen in an employee lunchroom are more likely to be covered than those that occur off work grounds.
Finally, an employee who became injured during a work-sponsored event may have trouble making a successful case for coverage, unless the event required mandatory attendance as part of the person’s job. Generally, injuries that occur at these company events will be eligible for coverage, but laws that require these protections are not the case in all states.
What Is Involved in the Appeals Process after a Workers’ Compensation Denial?
Injured employees have the right to appeal a denial of benefits for a work injury that was deemed unrelated to their job. The injured worker may appeal to the insurance company for them to reconsider. There may be additional steps necessary to ensure that additional evidence may be considered.
If it is allowed, compile records and evidence to support your case and submit them along with the request to reconsider. Obtaining statements from any of the witnesses to the event can be very helpful. Enlisting the help of a lawyer with experience in Workers’ Compensation claims can also prove wise.
Once the decision is final, the issue becomes a matter of filing a request for the state board of Workers’ Compensation to start the appeals process in most states. This must happen within a certain timeframe, usually within 180 days of the claim’s denial.
New Jersey Workers’ Compensation Lawyers at Kotlar, Hernandez & Cohen, LLC Provide Legal Support to Injured Workers
If you were hurt at work, you should be able to collect Workers’ Compensation for your injuries. Sometimes employers or their insurance providers attempt to bar workers from collecting their rightful benefits after a work injury, claiming that the injury was not job related. The New Jersey Workers’ Compensation lawyers at Kotlar, Hernandez & Cohen, LLC have extensive experience supporting the cases of injured workers who were disqualified from receiving fair compensation after a work accident. Our knowledgeable lawyers can help you build a case to support your claim by gathering evidence and making supportive arguments for your eligibility. Call us at 856-751-7676 or contact us online for a free consultation. Our offices are in Mount Laurel, Cherry Hill, Trenton, and Vineland, New Jersey; and Trevose, Pennsylvania. We serve clients throughout New Jersey and Pennsylvania.