Why Was My Workers’ Comp Claim Denied?

There are several reasons the insurance company denied your workers’ compensation benefit. Common reasons for claim denials include lack of medical evidence, claim errors, late claims, no eyewitnesses or a dispute about whether the injury was work-related. Some injuries are not covered under Florida Statute 440.02.

Regardless of why your claim is denied, you may qualify for an appeal to the Florida Bureau of Workers’ Compensation. Your first step in appealing your case is to consult a workers’ compensation lawyer in Pensacola, Florida. Thomas Uebeschaer can guide you through the appeal process and work on your behalf to get the compensation you deserve. 

Reasons Workers’ Compensation Claims Are Denied

1. Lack of Medical Evidence

Medical evidence often includes

  • Medical test results
  • Doctor’s medical notes
  • Medical bills and receipts
  • Photos or imaging
  • Any related documents

An insurance company examines medical evidence before deciding on your compensation claim. If the medical evidence is lacking or if it shows that the injury isn’t serious enough, the insurer or employer may deny your claim. Your attorney can gather all medical records and related documents when investigating the accident to ensure you have sufficient evidence.

2. Injury Is Not Work-Related

The injury you are seeking compensation for must be work-related. You must be injured in the course and scope of your employment during work hours. You would also be compensated if the injury occurred while carrying out your off-site work duties. 

The workers’ compensation insurance company would deny your claim if you were commuting to or from work because you are not officially on the clock. It would also deny your claim if you were performing your duties off the clock (i.e., you chose to work unauthorized outside official working hours).

3. Your Injury or Illness Is Not Covered Under Florida Workers’ Compensation

According to Florida Statute 440.092, there are exclusions and caveats to Florida workers’ compensation coverage, including

  • Accidents that occur while going to or coming from work
  • Recreational or social activities organized by the employer unless they are mandatory
  • Injuries that occur when the employee leaves work without permission
  • Intentional Injuries
  • Illegal acts
  • Deceit or insurance fraud
  • Injuries that occur as a result of drug or alcohol use

4. There Are Errors in Your Claim Application

A small mistake or omission on a form could prevent you from getting your claim approved. There may be discrepancies between the documented injuries and the accident report, or your application was missing information. Something as simple as a spelling mistake or entering the wrong code can derail your workers’ compensation claim. 

The best way to avoid workers’ compensation form errors is to let your attorney fill out the form. Your lawyer has a legal team that can investigate the accident to get the facts. They can fill out the form and ensure all information is accurate and complete. Your lawyer can also submit the form on your behalf and monitor the progress of your claim.

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5. You Missed the Deadline for Filing a Workers’ Comp Claim

According to Florida Statute 440.185, you have 30 days from the date of the accident to report your workplace injury. Your employer should report the injury as soon as possible but no later than seven days from knowing about the injury. The workers’ compensation insurance company must send you an informational brochure within three days of receiving notice from your employer. 

You may not qualify for the benefit if you or your employer miss the deadline for filing a workers’ compensation claim. 

Remember that you may still qualify for your benefit even if you miss the deadline. For instance, you may not know you are injured until several weeks after the accident. So, consult your workers’ compensation attorney in Pensacola, Florida, if you believe you are injured and want to pursue compensation. You may still qualify for coverage.

6. You Have a Pre-Existing Condition

Florida workers’ compensation generally does not cover pre-existing conditions. Employees with pre-existing conditions may see their requests for workers’ compensation denied, as employers may consider their conditions part of that pre-existing state.

However, a pre-existing condition does not necessarily disqualify you for a workers’ compensation benefit. 

If you have a pre-existing condition, the court will look for the major contributing cause (MCC) to determine if Florida’s workers’ comp benefits cover the injury. To be eligible for benefits, you must prove that the work accident is more than 50 percent responsible for your current condition. 

Florida law also allows for workers’ comp benefits if the work accident accelerates or aggravates a pre-existing medical condition. 

7. There Is No Eyewitness Testimony

Although eyewitnesses are not mandatory for a workers’ compensation claim, they are helpful. Your employer or attorney can interview coworkers or other people to get their account of what happened. They may gather employees’ names and contact information to verify the information. 

If no one witnessed your injuries, the insurance company might use that as grounds to deny your claim. For this reason, your attorney will speak with eyewitnesses who can corroborate your story and back up your claim.

To learn more about workers’ compensation in Florida, read our recent blogs:

Hire Thomas J. Ueberschaer, P.A., to Represent You Today

When you are ready to move forward with your workers’ compensation case, we are here to help at every step. Thomas J. Ueberschaer, P.A., provides comprehensive legal services for victims of workplace accidents in Florida. Contact us today to get started with your claim.

We will answer your questions, address your concerns, and work on your behalf to take on the insurance companies. To schedule a free case evaluation, call us at 850.741.7381.