Hardworking individuals are injured every day. These men and women work diligently for their employers only to have insurance companies and employers often refuse to compensate them for their injuries. Denials of workers’ compensation claims can occur for a variety of reasons, but below are several common reasons why employers and insurance companies deny the claims of injured workers.
- Reporting Discrepancies- An insurance company is likely to deny a claim if the accident report does not correlate with the initial medical report. Moreover, an insurance company may not grant much credence to an accident report if there are no witnesses even if there is a clear nexus between the accident report and the injuries reported in the initial medical report.
- Delays in Reporting- In South Carolina, there is a two year statute of limitations on workers’ compensation claims. If one fails to bring a claim within two years of the date of the accident- or in limited cases dealing with occupational disease, within two years of when one knew or should have known that his injury was a result of his employment- the claim will most likely be barred forever. Additionally, the injury must be reported within 90 days of the accident. However, injuries should certainly be reported to a supervisor or employer as soon as possible.
- Inappropriate Medical Care Decisions- First, there must be medical evidence to back a workers’ compensation claim. Regardless of how much pain a worker is in, her claim will be denied unless she has visited a doctor. The benefits of seeking medical attention immediately after reporting are twofold: the injured worker gets the medical help she needs, and she can have a physician verify her injury. Furthermore, in South Carolina the employer chooses the medical provider that treats an injured worker. So, benefits will most likely be denied if one visits an unapproved medical provider. Lastly, claims could be denied if a worker fails to follow the approved medical provider’s instructions.
- Employer Skepticism- Employers often doubt that an ailment is present or if an accident ever occurred. Even if an accident clearly occurred at work, employers may still dispute a worker’s claim on the basis that the ailment preventing him from working or causing him pain was not caused by his accident. However, a preexisting condition does not bar recovery for a subsequent injury that aggravates said preexisting condition. The South Carolina legislature has codified cumbersome standards for establishing when a claim is compensable despite or in conjunction with a preexisting condition.Moreover, employers frequently meet workers’ compensation claims with skepticism regardless of the merits of the claim. Many employers seem predisposed to assume injured workers are “malingering” or exaggerating and faking their pain in order to skip work or make undeserved financial gains. That position leads to the denial of benefits for many exemplary workers. This issue is only made worse when the injury reported is difficult for a physician to objectively identify. For example, many workers suffer from severe pain, but their pain is simply inexplicable by medical evidence. A worker who suffers from pain that does not have a clear medical explanation is no less deserving of compensation, but she is certainly placed in a disadvantageous position that requires much more effort to overcome stubborn employers and insurance companies.
- Additional Factors- As a general rule, an injury sustained while traveling to or from work is not compensable unless the situation falls within one of five exceptions. Furthermore, claims will be denied if they are not medically justified; claims based on minor injuries that in no way impede work or cause pain will not be granted. If an injured worker tests positive for illegal drugs on a test administered by a medical provider after an accident, the insurance company and employer will almost certainly deny a claim on that basis alone. Being intoxicated when the injury occurs is a hurdle that is particularly difficult to overcome. However, a positive drug test is not an automatic bar against recovery provided the injured worker was not intoxicated at the time of the accident or if the intoxication did not cause the accident. Lastly, employers likely will deny claims that arise out of horseplay or roughhousing on the job. Determining whether or not that denial is justified frequently depends upon who initiated the horseplay.
- Not Talking to an Attorney- Going into a hearing without an attorney advocating on your behalf can often lead to negative consequences. Without doubt, the insurance companies will have an attorney. Retaining an attorney could make all the difference in the outcome of your workers’ compensation claim.
Many of the above matters can be brought to naught with diligent advocates working on your behalf. Often times, denials are a result of predisposed positions taken by employers and insurance companies or are only supported by “creative” arguments or interpretations of the law. The attorneys at Chappell, Smith & Arden, have helped injured workers overcome dozens of the issues that frequently plague workers’ compensation claims.
If you have questions about your claim, please do not hesitate to contact the Columbia SC injury attorneys at Chappell, Smith & Arden by calling (800) 531-9780 or emailing us via the contact form on this page.