When Will a Workers Compensation Claim Be Denied?

Employee injuries are common in every industry, which is why most employers offer workers compensation insurance. Unfortunately, workers compensation won’t cover every injury. There are a few circumstances in which a workers compensation claim may be denied.

Intentional Injury

Some employees may be tempted to take advantage of an employer’s workers compensation policy. Any injury that is deemed as intentionally inflicted by an employee will not be covered. For example, if an employee is caught on camera spilling water on the ground and immediately slipping in it.

Fights Instigated by the Employee

There are bound to be disagreements in the workplace. It is crucial that things deescalate before they grow physical, but this isn’t always possible. If an employee instigates a fight with another employee or customer and is injured, these injuries will likely not be covered.

Certain Preexisting Conditions

Workers compensation will only cover preexisting conditions under specific circumstances. That is, if your work directly worsens or exacerbates an old injury, you may receive workers compensation insurance. If an injury flares up that cannot be tied to your work, however, a workers compensation claim may be denied.

Injuries Unrelated to Work

Along the same vein, injuries an employee suffers while off the clock and away from work likely won’t be covered. There is some gray area, such as if you leave work to do a task for your employer. Otherwise, injuries that occur while the employee isn’t working or on the premises will not receive workers compensation benefits.

How is Workers Compensation Decided?

When you file a workers compensation claim with your employer, the employer will notify the insurer who provides the policy. The insurer will then send an underwriter to investigate the claim.

An employee wanting workers compensation benefits must seek immediate medical attention for their injury from one of the approved health providers on their employer’s policy. If the employee fails to seek medical attention within a certain time frame as specified by the policy (usually 30 days after the initial claim), a claim may be denied, as the insurer will deem the injury not serious enough for compensation.

If a workers compensation claim is approved, the amount of compensation an employee will receive is determined on the seriousness of their injury and how long they will be unable to work. Employees should always check their insurer’s workers compensation policy to understand the coverage and limits available to them.

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