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Reasons for workers’ comp denial and next steps

On Behalf of | Nov 30, 2020 | workers' compensation

In most cases, when workers sustain injuries in the workplace they qualify for workers’ compensation benefits. However, even though workers’ compensation is a no-fault system, denials do occur.

When workers’ comp denials occur, workers have the right to file an appeal. However, before they do, they need to determine the reason for the denial in the first place.

Common reasons for the denial of workers’ comp benefits

If an insurance company denies a workers’ compensation claim, it should explain its reasons for doing so in the denial letter. According to FindLaw, while reasons for denial run the gamut, the most common explanations are as follows:

  • Failure to report an injury within the timeframe specified by state law
  • Failure to file a claim within the specified timeframe, which is typically between 30 and 90 days
  • Filing a claim for a non-compensable injury, such as a stress-related injury
  • Failure to obtain recommended medical treatment
  • Lack of evidence that proves an injury is work-related
  • Filing for an ineligible injury, such as one that is the result of horseplay or an outside hobby

Once a claimant identifies the reason for a denial, he or she should consult with a workers’ compensation lawyer.

Next steps

Per the Minnesota Department of Labor and Industry, the first step an injured party should take after learning of the denial is to call the insurance claims adjuster. He or she should explain the issue and try to see if the parties can resolve it through discussion.

If discussion does not result in a favorable outcome, the claimant should contact an Alternative Dispute Resolution specialist with the DLI. The specialist will work with the claimant to attempt to resolve the issue, but if further attempts fail, he or she will inform the injured party about the dispute resolution process. If the claimant chooses to proceed, he or she and the other party will go through mediation in an attempt to come to a quick and cost-effective resolution. If mediation proves ineffective, the next step is to file an appeal and submit a request for a hearing.