Why was my work injury claim rejected?

6 Common Reasons for Denial of Workers’ Compensation Claims

In a just world, employees injured at work while performing their job duties will receive the workers’ compensation benefits they are entitled to with minimal pushback from the insurance companies. Sadly, we do not live in a just world. Many legitimate work injury claims are denied by workers’ comp insurance providers, causing significant delays in medical treatment and undue financial hardship for injured workers. Below are the most common reasons insurance companies use to deny workers’ compensation benefits: 

1. You have a pre-existing condition: Insurance companies will claim that they are not responsible for your injury because you had a long-standing chronic condition. Having a pre-existing condition does not disqualify you from workers’ compensation benefits even if you injure the exact same body part at work. Under the Illinois Workers’ Compensation Act, if the work injury caused an aggravation or worsening of a pre-existing condition you are entitled to workers’ compensation benefits. 

2. No notice of accident to the employer: You have 45 days to report your work accident to your employer. Notice must be given to your supervisor or someone in a position of authority. Telling your co-worker about a work accident is not proper notice. Even though you have 45 days to report a work accident, it is in your best interest to report the accident to your supervisor immediately, no matter how minor you think the injury is. 

3. A negative IME report: Under the Section 12 of the Illinois Workers’ Compensation Act, the employer has the right to have the injured employee examined by a doctor of their choice for an Independent Medical Examination (IME). An IME is the insurance company’s primary tool to deny workers’ compensation benefits. 

The IME physician may opine that you can return to work (despite your own doctor’s off work recommendation), that treatment is no longer needed, and/or that your condition is not work-related. If this is the case, the insurance company will deny benefits. However, it is important to know that the IME doctor does not have a final say on your eligibility for workers’ compensation benefits. Your treating physician is in the best position to determine your work status and your course of treatment. You will need a knowledgeable and aggressive attorney willing to go to court and fight for your benefits and your own doctors recommended treatment.

4. Positive drug test: Many employers will require injured employees to submit to a drug test. If the drug test comes back positive, the insurance company may deny your claim. However, a positive drug test does not automatically disqualify the injured worker from workers’ compensation benefits. The Illinois Workers’ Compensation Act provides a “rebuttable presumption,” which means that you can present evidence to defeat the presumption that you were impaired at the time of the work injury. Therefore, a positive drug test, alone does not nix your workers’ compensation claim.

5. Injury did not occur at work: The insurance company and your employer will claim that your injury did not occur at work. Your employer may claim that the accident did not even occur or that it happened at home. Your employer may claim that you were off the clock or on break when the injury occurred. While typically injuries occurring off the clock are not compensable, there are exceptions to this rule. For example, injuries that occur while an employee is on break performing activities for their personal comfort are compensable in Illinois. Also, “off-the-clock” slip and falls that occur in an employer owned parking lot when the employees are entering or leaving work are covered work accidents. There are also special exceptions carved out for traveling employees who are “off-the-clock” when they were injured, but because their job required them to be away from home their accident is also compensable.   

6. Discrepancies in the medical records: There may be discrepancies between what you reported about the accident and what was documented in the medical records. There are also times when the medical records make no mention of a work accident. These situations are red flags for insurance adjusters to deny your claim. Therefore, it is extremely important to give a detailed accident description to your medical providers (especially during your first visit) and make sure the accident description is well-documented in the medical records.      

If you are denied workers’ compensation benefits for any reason, it is important that you retain an experienced and knowledgeable Illinois workers’ comp attorney who will aggressively fight for your benefits. Contact the attorneys at Woodruff Johnson & Evans. We work hard for hard-working people.