Why are claims denied?

Claims are denied so that an insurance company can withhold in providing benefits to Injured Workers. There are two types of claim denials. There is the denial of the entire claim.  There is also a partial denial of the claim.  For instance, a partial denial could be to a body part or to a particular benefit.

Claim Denials can be done for many reasons. Denials can be legal, factual and also based upon insurance coverage.

Examples of Denials are as follows:

  • Denial based upon Employment. Defendant can deny that the Injured Worker worked for the Insured Employer. For example, a McDonald employee may actually work for a franchisee corporation and not the actual McDonald Corporation. Defendant can also deny that the Injured Worker was actually an employee. For example, the Injured Worker may have signed an Independent Contractor Agreement.
  • Denial based upon Coverage. Defendant can deny that it provided workers’ compensation insurance to the employer at the time upon which the Injured Worker got hurt.
  • Denial based upon Lack of AOE/COE.  Defendant can deny the claim if Injury did not arise out of and in the course and scope of employment. For example, the injury date was not one upon which the Injured Worker was not working.   Or, the Injured Worker was on a lunch break when the injury occurred.  Or, the Injured Worker was driving home when the accident occurred. (NOTE:  Denials based upon factual ones does not mean that the Workers’ Compensation Appeals Board would find that the claim was actually work- related.)
  • Denial based upon Lack of Information. Defendant can deny a claim if they have not received information that in fact an injury occurred.  The Defendant may not have received a medical report indicating the accident was work-related.   Also, the Defendant may not have received information from the employer that the accident happened at work.
  • Denial based upon Medical Information. Defendant may deny a claim if a doctor indicates that the medical condition was not a result of the work activity.  For example, someone may have a heart attack at work but the doctor may have reported that it was not caused, aggravated or accelerated by employment.

Denials can be fought and the Workers’ Compensation Appeals Board has the power to find injuries in denied cases.  If you have a denied claim, consult an attorney or the Information and Assistance Officer at the WCAB immediately!  There are time limits to fight denials. If you fail to take prompt action, you may become barred from pursuing your claim.

Law Offices of Edward J. Singer

At the Law Offices of Edward J. Singer, we specialize in helping our clients with their workers’ compensation claims. With more than 20 years of expertise in defending workers’ rights, we are here to assist with any questions a person in Southern or Central California who receives workers’ compensation may have. We welcome anyone who needs assistance to contact us today concerning any workers’ comp questions or issues.