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Reasons for workers’ comp denials

On Behalf of | Feb 8, 2021 | Workers' Compensation |

Worker’s comp benefits in California provide income for workers who can no longer perform their job because of a disability. The Social Security Administration has stringent requirements to prevent abuse of the program. A large percentage of claims get denied initially for many reasons, but the claimant may appeal.

Not reporting on time

Many claims get denied because the employee failed to report it in time. Each state sets its own time limits to file claims. In California, workers have 30 days to report workplace injuries. If a worker delays reporting, the insurance company may think the worker really didn’t get injured.

Filing a claim differs from filing a report, and each state has a statute of limitations for filing. In general, workers have one year from the injury date to file a claim in California.

Injury didn’t happen at work or was not work-related

Workers can only receive workers’ compensation for injuries that happen at a place of employment or on assignment for an employer “in the scope of employment.” If they fall in a restaurant on lunch break, the employer would not likely be liable. If they fall while delivering a parcel for an employer, they would likely be covered.

Injuries resulting from being required to attend team-building events or events that benefit the employer may be covered. Injuries from employee carelessness, personal conflict, practical jokes or intoxication rarely get covered.

Injury not covered

Workers’ compensation only covers injuries that prohibit an employee from performing at full capacity. Soft tissue injuries, such as sprains, rarely get covered even if the employee can’t work for several days.

Some states cover PTSD from single events and depression over time, but the employee has to prove that their job caused it. Just simply being stressed won’t be enough to file a claim. Many claims for mental illness get denied initially since some issues can be tricky to prove.

Workers have the right to appeal denied claims that they feel are legitimate. An attorney may be able to help them appeal.