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Reasons workers’ comp may deny your claim

On Behalf of | Apr 22, 2024 | Workers' Compensation |

When workers in North Carolina suffer injuries on the job, they typically turn to workers’ compensation to cover medical bills and lost wages during recovery. However, not all claims sail through the approval process smoothly.

Sometimes, workers face the challenge of having their claims denied. This can be a frustrating experience, especially when the denial comes unexpectedly, and the reasons behind it are not immediately clear.

Injury not reported in time

One of the most common reasons for a claim denial is failing to report the injury within the required time frame. In North Carolina, workers must report their injuries to their employer verbally or in writing within 30 days of the accident. Missing this deadline can lead to a claim denial, as it could be argued that the delay in reporting impacted the ability to verify the circumstances of the injury.

Dispute over the injury being work-related

Workers’ compensation only covers injuries that are directly related to an employee’s job duties or work environment. If there is a dispute about whether the injury occurred while the employee was performing work-related activities, the insurance company may deny the claim. Employers or insurance carriers sometimes challenge a claim if they believe the injury happened outside of work or due to non-work-related activities.

Lack of medical documentation

Adequate medical documentation is important for a workers’ compensation claim. If an employee fails to provide sufficient medical evidence that supports the claim, such as details about the extent of the injuries and the treatment required, workers’ comp may deny the claim. Proper documentation from healthcare providers is necessary to establish that the injury is serious and related to the job.

Pre-existing conditions

Workers’ comp may also deny the claim if doctors believe the injury is primarily the result of a pre-existing condition rather than a work-related incident. If an insurance carrier believes that the current injury is just an aggravation of a previous condition, they may refuse the claim unless the worker can prove their job duties caused or exasperated the injury.

Understanding these potential pitfalls can help workers navigate the workers’ compensation system more effectively. By knowing how to proceed, employees can enhance their chances of claim approval and secure the benefits they need for recovery.