Reasons Why a Case May Be Denied and What Can Be Done

Workers Compensation Claim Denied

There are many reasons why a workers compensation claim may be denied, but a denial does not mean that the case is over.

Some common reasons why a claim may be denied include:

• fraud
• major contributing cause
• preexisting conditions
• and no accident in the course and scope of employment

Workers Compensation Fraud

A case is generally denied based on fraud when untruthful statements have been made in a deposition or to treating physicians. For example, an injured worker may have suffered an injury to the same body part in the past, but does not disclose this when asked about it in a deposition or when giving his or her medical history to a treating physician. If a case is denied based on fraud, it may be difficult to overturn it because the Judge of Compensation Claims must determine whether the untrue statements were intentional and made for the purpose of securing workers compensation benefits. That being said, each situation is different and it may be possible to prove that such statements were not intentionally made. An example is if questions asked during a deposition were not properly understood by the deponent, making it an issue which may have to be litigated.

What is Major Contributing Cause?

Another reason why a claim may be denied is based on major contributing cause. Many times major contributing cause and preexisting conditions go hand in hand and are used as a defense by the Employer/Carrier at the same time. For example, an injured worker that has suffered an injury to the same body part in the past may have his or her case denied by the Employer/Carrier on the basis that the injury is preexisting. In order for an injury to be compensable under workers compensation, the “major contributing cause” of the injury must have been the workplace accident. Major contributing cause is satisfied when an authorized physician opines that the causation of an injury is 51% or more due to the work accident.

The Employer/Carrier may deny a claim based on the major contributing cause before an injured worker has even treated with an authorized physician, placing the burden of proving causation on the injured employee. If a case is denied based on major contributing cause right off the bat or if the claim is initially compensable and an authorized physician opines that the major contributing cause is not the work accident, an Independent Medical Examination (“IME”) may be needed to fight the denial. An IME is a one time exam performed by a physician on the Carrier’s network that can be selected by the injured worker in order to have that physician opine on the injury. Some insurance companies have an arrangement which requires them to pay for the IME, but most do not which means that the injured worker may have to pay for the IME out of pocket.

Assuming the injured worker has an IME performed which opines that the major contributing cause is the work accident, the Employer/Carrier is also entitled to their own IME. If the Employer/Carrier’s IME gives a different opinion than that of the injured worker’s IME, an expert must be appointed by the Judge to break the tie. As you can tell, a denial based on major contributing cause is generally a complicated issue and an injured employee is generally advised to hire an attorney in this situation.

Accidents not Covered by Workers Compensation

A claim may also be denied on the basis that an accident did not occur in the course and scope of employment. An example is if a person that is leaving work after their shift has ended is involved in a car accident while going home. This person would not be covered by workers compensation as the accident did not occur in the course and scope of their employment since he or she was on their way home at the time of the accident. However, if an accident occurred while the employee left the office and was on his or her way to see a client, then the accident would have occurred in the course and scope of the injured worker’s employment. Situations involving motor vehicle accidents are somewhat tricky and the help of an attorney is usually needed to determine whether the accident should be covered by workers compensation.

Has Your Claim Been Denied?

As you can see, a workers compensation claim may be denied for many reasons, but that does not mean there is nothing that can be done after that time. That is why it is important to hire a Workers’ Compensation attorney who handles these types of situations in order to get advice about how to proceed with the case. If you are in this situation or know of someone who is, have them give us a call at (772) 461-9181.

This article is general information, not legal advice. Every case is different - call (561) 598-7120 for a free consultation about yours.