What are the reasons workers comp claims are denied?

What are the reasons workers comp claims are denied?Going to work daily is a responsibility for most people. While most employees can get through their day without incident, injuries can happen in the workplace. Unfortunately, some injuries can be bad enough that they will require medical attention, resulting in an employee needing to take time off to require or even prevent their ability to work in the future.

Fortunately, most employers with three or more employees in North Carolina are required by law to carry worker’s compensation insurance. This coverage will provide financial support and protection to employees that are injured while working on the job. While workers’ compensation insurance is intended to provide coverage to hurt employees, there are situations in which an insurance claim will be denied. There are a few reasons why one of these insurance claims could be denied.

Injury Was Not Related to Work

Workers’ compensation is a unique form of insurance in that it provides coverage for injuries that specifically only takes place when you are working. One of the reasons why a claim may be denied is if it has been determined that the injury did not occur while you were working. Generally, the injury must have occurred while you were performing tasks related to your job. In most situations, you will need to prove that your employment was a leading reason why the injury occurred. If you were injured while you were not at work, your claim will likely be denied.

Claim Was Not Filed on Time

In the state of North Carolina, there are time limits in which a worker’s compensation claim needs to be filed. The process of filing a claim includes both providing notice to your employer and filing the formal claim. In most situations, you should provide notice of your injury in writing to your employer within 30 days. As it is not always clear what the scope of your injuries and damages is within this period of time, you have additional time in which to file the formal claim. Typically, you will need to file the formal insurance claim within two years of the incident date. While there are always situations in which you can get additional time for valid reasons, delaying the claim date for too long is a reason why your claim can be rejected.

Lack of Witnesses

Whenever you are going to file the notice and an eventual workers’ compensation insurance claim, it is always helpful for you to have as full of claim with as much support as possible. This can include having witnesses that are around to support your claim and story. While you do not necessarily need to have witnesses or direct evidence, claims could be denied without it. Due to this, gathering a piece of evidence including witness statements, video surveillance, or other evidence will always be helpful as you are trying to have your claim approved.


Injury was Intentional

A worker’s compensation insurance plan is designed to provide protection to employees that are injured while performing functions at jobs. This almost always means that the employee should be following proper safety protocols. Unfortunately, there is always a chance that an employee could try to take advantage of this system and get injured to receive compensation and paid time off away from work. If it has been determined that an employee tried to get hurt on purpose, the worker’s compensation charge could be

Inconsistent Report

If you are going to file a workers’ compensation claim, the insurance provider and your employer are both going to spend time assessing the claim to ensure it is valid before approving it. This part of the process will include making sure that your claim, medical reports, witness statements, and other information are all consistent and make sense. If there are glaring discrepancies between your statements, medical reports, and other information, it could be a red flag caught by the employer and workers’ compensation firm. In many cases, they will either ask a variety of follow-up questions or deny the claim due to concerns of fraud.

Under the Influence of Drugs or Alcohol

In practically all situations, an employer will expect and require that an employee come into work sober and without any alcohol or other substances in their body. This is due to the fact that sober employees are more productive and will make better decisions than those that are under the influence of other substances. However, they will also be safer when operating equipment or doing anything else in the workplace. If you are injured while working and are under the influence of drugs or alcohol, the insurance claim could be denied.

No Cooperation During Review Process

There can be a lot of work that goes into reviewing and approving a workers’ compensation claim. Generally, the larger the claim, the more work the insurance provider will put into assessing it. The company may require that you provide recorded statements or sign documents that will allow the company to gain access to your past medical records. Someone filing a claim will not be required to provide this information, but not doing so can be a sign of a lack of cooperation. If you do not properly cooperate in these situations, your claim could end up being denied.

If you are injured while at work, you should be approved for workers’ claim insurance support. While this insurance is available to provide support in these situations, claims are denied from time to time. If your claim has been denied, it is important to hire an attorney for support. When you need assistance with a denied workers’ comp claim,  you should reach out to the Sumwalt Anderson Law Firm.


The legal team here can help people all over the Charlotte area with their workers’ compensation support needs. When you work with them, they will first provide a full consultation on your case to help you understand if you have a valid claim for an appeal. They can then provide any additional support that is needed to build a plan that is needed. This can include filing a formal appeal, discussing and negotiating the situation with other parties, and handling any necessary legal deliberations. This can help ensure that your rights are properly represented and that you receive the insurance support you are entitled to

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