An insurance company has 90 days to investigate a claim. When an adjuster gets a new claim on his or her desk, they typically make a three-point contact. First, they will call the injured worker and get their side of the story of what happened. Secondly, they will call the employer and get the employer’s side of the story including were there any witnesses and will flat out ask the employer if they think that this person is telling the truth. The third call is usually to the doctor where the injured worker has been sent for treatment. The insurance company will provide the doctor with a fax number so the doctor will know where to send treatment reports.
There are many reasons a workers’ compensation claim may be denied. We’ll look at a few of the reasons here.
Post Termination Defense
Sometimes people get hurt at work and they don’t let their employer know. Then, for whatever reason, they later leave the employer. No longer employed, they file a claim and it is denied.
This denial is based on an insurance company’s defense called the “Post Termination Defense”. The only way to get around this defense is to be able to provide a judge with evidence that was created prior to the termination of employment, that there was an injury at work. The best evidence would be medical evidence where the injured worker went to the doctor and got some treatment and told the doctor that they were hurt at work and this was subsequently put into the medical record.
For example, sometimes people have cumulative trauma injuries and they don’t realize that is was caused by their work. One example might be Carpal Tunnel Syndrome which happens when people do a lot of keyboarding or fine manipulation with their hands and fingers. Maybe they went to a doctor on a non-industrial basis no knowing why their hands were sore. Once a doctor is aware of the kind of job a worker does, they may note the injury is a result of work duties. This medical evidence can be used to overcome the “Post Termination Defense”.
Another situation where a claim is denied is where an injured worker did not report the injury right away. This is very common in workers’ compensation. Someone strains their back lifting something heavy and the result is that they are in a lot of pain. Now, this may have happened many times before and it was always got better in a day or two. So they continue to work and they are in pain. They may even take a day off or two or maybe the injury happened on a Friday and they decided to let the weekend go by confident that by Monday they will be back to normal. At some point they determine that they are not getting better and then decide to file a claim. Now, because the claim was not filed within 24 hours, the insurance company decides to go ahead and issue a denial.
Other evidence that can be used would be whether the injured worker discussed being sore with another employee. Let’s say that the injured worker fell, or something like that happened. The question to ask is, “Was it witnessed?” A witness can be brought to a trial and testify to a judge that yes, they saw this worker fall and get hurt. Even if it wasn’t witnessed, if the injured worker complained to another employee after injury and told them what happened, that can be used as evidence. So, the three forms of evidence that can turn a denial into an acceptance would be either medical evidence before termination, a co-worker who witnessed the event, or a co-worker who didn’t see it happen but were told about it by the injured worker shortly after it occurred.
To refresh, even though the insurance company has 90 days to investigate a claim, sometimes claims are denied right away. This can be based on non-reporting or late reporting. It can be based on a Post Termination Defense, meaning they filed the claim after they either were fired or quit their job.
Lack of Medical Evidence
The third reason a claim may be denied is that the injured worker files a claim and then doesn’t go to the doctor. If the insurance company has no medical evidence to support that there is any type of injury, they will deny the claim.
The fourth way that a claim may be denied is if the injured worker was sent to have a drug test immediately after the injury and they tested positive for drugs or alcohol. Intoxication is always a valid affirmative defense that allows the insurance company to deny the claim. However, this denial can be overturned if it can be shown that the intoxication was not responsible for the injury. In the case of intoxication, you would need medical evidence to support that their level of intoxication was not enough to impair the person such that they would get injured. These cases are difficult. A good workers’ compensation attorney can help injured workers’ in this situation.
The fifth reason that a claim might be denied is if there was an altercation between the injured worker and someone else, where there is an allegation that the injured worker was the initial aggressor. In all these situations, the way to overcome a denial is medical evidence to support an injury and witnesses to testify that the injured worker was not the initial aggressor if the injury was caused by an altercation.
In all these situations it is suggested you obtain a workers’ compensation attorney. This is because what is necessary to overcome all these denials is an AOE/COE trial. What AOE/COE means is Arising Out Of Employment or in the Course Of Employment trial. In that type of trial, the judge is only ruling on one issue: Is there a work injury? AOE/COE trials require medical evidence to support a work injury, testimony as to how the injury occurred, witnesses, to testify they saw the work injury happen, or heard about it happening.
Contact a Sacramento Workers’ Compensation Lawyer
Hope this answers some questions you may have about why a claim is denied and what you can do about it. For any additional questions please call The Law Office of Alice A. Strömbom at 916-444-7557 for your free consultation. We’re here for you.
Sacramento Workers’ Compensation Attorney, Alice A. Strömbom, focuses exclusively on Workers’ Compensation Law and the rights of injured workers. She is very familiar with the tactics insurance companies use to avoid providing the medical treatment and disability benefits injured workers deserve, and has a recognized track record in combating such issues. Contact us today for a free, confidential consultation and case evaluation.
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