Common Reasons for Workers’ Compensation Denials

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South Carolina law requires that employers carry workers’ compensation insurance to protect workers in case they suffer a work-related injury or illness. A serious medical condition from the workplace can result in substantial medical expenses and the inability to work for a period of time, which can leave workers feeling severe financial strain. That is when workers’ compensation benefits are supposed to step in and cover costs of the necessary medical treatment, as well as compensate workers at least partially for the wages they lose from their injuries.


When you alert your employer to your on-the-job injury or illness, you likely expect your claim for workers’ compensation benefits to be automatically approved. After all, isn’t that why workers’ compensation insurance coverage exists? Unfortunately, a large number of workers with work-related medical conditions are devastated to learn their claims were denied. A denial can be partial and can refuse to cover certain medical care or to pay for certain days missed from work. On the other hand, some injured workers receive a complete denial and are told they will receive no benefits at all. Understandably, people in this situation feel helpless and highly concerned about how they are going to pay their bills and get the medical treatment they need.


Like any other type of insurance company, workers’ compensation insurers are aiming to limit liability and payouts whenever possible. As a business, these companies want to profit as much as possible and that entails denying claims whenever possible. In addition, you employer may want to keep premiums down and, therefore, may try to deny your request for workers’ compensation benefits.


The good news is that there are ways that an experienced South Carolina workers’ compensation attorney can help you appeal a denial in several ways. This first thing we do, however, is determine the reason behind your denial. The following are many different reasons why your employer or its insurer may try to deny your claim.


  • Filing errors — There are certain time limits and requirements for you to file a workers’ compensation claim. For example, you must notify your employer that you have sustained a work-related injury or illness within 90 days of the date of the injury. In addition, you have up to two years to file a claim for workers’ compensation benefits. You must follow the specific procedures set out by your company or its insurer to file the claim and provide all the necessary information and paperwork. If you fail to do so, you may find that all or part of your claim may be denied. To avoid this, you can seek assistance from a workers’ compensation attorney during the filing process.


  • Claiming your injury was not work-related –– In order to qualify for benefits, you must have suffered the injury or medical condition as a result of your job. If your employer or the insurance adjuster believes that you sustained the injury outside of work, your claim may be denied. For example, if you drive as part of your job and you ran a quick personal errand and were in a car accident, your company may claim that you stepped far enough outside of your job duties to disqualify you from benefits. Another common example is if you have an occupational disease, your employer can claim it is not work-related but is instead a disease that you could have contracted in everyday life.


  • Claiming you do not need certain types of medical care — If you are injured and you elect to undergo a certain type of procedure or surgery for your injury, you may find that the workers’ compensation insurer comes back and refuses to cover the treatment. The insurance company may claim that the surgery was unnecessary or that there was a less costly way to treat your injuries and may deny payment. However, our attorneys believe you should be able to have control over your own medical care and you should not be denied simply because you made a personal decision regarding a course of treatment.


  • Claiming you did not need as much time off work — After an injury, many medical professionals may recommend that you take a certain amount of time off work to heal. You may also have to miss work if your injury prevents you from performing your job duties. While you are off work, you should be granted income replacement by the workers’ compensation insurer. However, a company may deny benefits for income replacement if they believe some of the time you took off work was not medically necessary. You can prove that you needed the time off by providing evidence that you received medical recommendations as such or by demonstrating ongoing impairments that prevent you from working.


  • Claiming your condition does not constitute a disability — If you do have ongoing impairments that prevent you from working, you may file a claim for disability payments. Often, an insurance company will question whether your impairment really constitutes a true disability under the law and will try to assert that you do have the ability to work in some capacity. This type of appeal can require complex medical evidence and occupational analysis.


  • Wrongful denial — In a few cases, an employer and/or its insurance company may simply wrongfully deny a valid claim even though they know the claim should be approved. In such cases, we can work to demonstrate that your claim was intentionally wrongfully or even fraudulently denied and will fight to get you the benefits you deserve. We will work to hold your employer responsible for its bad faith actions.


Contact a South Carolina Workers’ Compensation Lawyer for Help


An initial denial does not necessarily mean that you will not be receiving workers’ compensation benefits. However, if you receive a denial, you should never wait to discuss your situation with an experienced South Carolina workers’ compensation attorney. The appeals process can be complicated and the team at The Law Offices of Steven M Krause PA can guide you through the entire appeals process.  Call us today for assistance.


We help people like you every day.