Many Workers’ Comp claims have complicated facts and nuanced issues. Insurance companies, however, tend to see certain issues as grounds to deny the entire claim.
Insurance companies will look for red flags, such as anything that looks like fraud or abuse, as grounds for a denial. Insurance companies look for a roster of common issues to base their denials on, though many of these can still be reversed or overturned by taking your case before a judge.
For a free case review, call Cardamone Law’s Certified Pennsylvania Workers’ Compensation Lawyers today at (267) 651-7945.
Common “Red Flags” for Workers’ Comp Claims
Insurance carriers have broad latitude to deny claims as long as they have reasonable grounds to do so. You can get their initial denial overturned, but it takes getting a Pennsylvania Workers’ Comp lawyer and fighting the claim – something they hope you will not bother doing.
If insurance carriers see any of these issues in your case, they are likely to deny the claim on that basis and move along:
Fraud
If there are mistakes in your filings that lead the insurance carrier to think you are committing fraud or filing a false claim, they will shut the claim down quickly. Never exaggerate how bad your injury is or lie about the facts, as that could be actual fraud.
Causing Your Own Injuries
Along the same vein, people sometimes file claims for injuries they caused themselves intentionally. If someone hurt themselves on purpose with the goal of filing a Workers’ Comp claim, that would be fraud. On the other hand, many accidents that workers cause themselves can still lead to valid claims. Insurance carriers, though, are not always concerned with the distinction.
Drug or Alcohol Use
Similarly, accidents caused by drug or alcohol use are not payable. However, the drug/alcohol use has to be the actual cause, not some other negligent act. The insurance company might not care about this distinction and simply deny any claim involving drinking or drugs.
No Witnesses
If there was no one around to see what happened to you, it can be harder to prove your claim. The insurance carrier may assume you injured yourself or made up the accident.
Hiding Work or Physical Activities
If the insurance carrier finds out you have been secretly working while trying to claim Workers’ Comp for a disability, it will hurt your case. Similarly, if you are caught doing physical activities like snowboarding or running a marathon while you are claiming you are disabled, insurance carriers are likely to question your disability status.
Timing
If the timing of your injury is suspicious, they might investigate it as fraud. For example, if you were potentially facing discipline or firing, the timing might be seen as “too convenient” to be a coincidence, leading to closer scrutiny.
Can My Claim Be Denied Because of Red Flag Issues?
Many of these issues are grounds for denial, especially suspected fraud, intentional injury, drug/alcohol use, or mischaracterizations. However, insurance companies usually do not have clear evidence to prove these issues this early in your case.
Instead, they will start with suspicion, then investigate further. Insurance carriers can request additional information about your injury and might even resort to sending investigators after you. Ultimately, you should work with a lawyer who can talk to the insurance carrier, supply the additional evidence, and put suspicions to rest.
If you are not committing fraud or lying about your injury, we can gather evidence to help prove that.
What to Do if My Employer’s Insurance Denies My Workers’ Comp Claim?
Workers’ Compensation cases are not over when the insurance carrier denies you. Many cases are granted, and benefits begin soon after that. But our lawyers often need to take cases before a judge to get the initial denial overturned.
If the insurance carrier denies your claim, we can file for a Workers’ Comp hearing where a judge will review the case and make their own determination. This overrides the insurance carrier’s denial and gets you the benefits you need.
Can You Appeal Workers’ Comp Denials?
Filing a Claim Petition with a Workers’ Comp Judge (WCJ) usually only happens after the insurance carrier denies the claim. This is not technically an appeal and is more like an escalation of the initial claim to court.
However, if the WCJ denies your claim, we can also appeal that decision to the Workers’ Compensation Appeal Board and then the Commonwealth Court. We can even appeal to the Pennsylvania Supreme Court, though they can deny the appeal and leave the lower court’s ruling in place.
What Evidence Do I Need to Overturn the Insurance Carrier?
When insurance carriers get it in their heads that your claim has red flags and should be denied on those grounds, it often takes more evidence to change their minds. In some cases, we may be able to negotiate a settlement after providing them with more evidence, or else we might need to provide the evidence to the WCJ and get the Claim Petition granted at a hearing.
In either case, the following pieces of evidence usually help your case:
- Your testimony
- Testimony and depositions from other witnesses
- Security camera footage of the accident
- Medical records linking the injury to the accident
- Doctor’s reports about the cause of injury
- Doctor’s reports about your condition, disability, limitations, and necessary work accommodations.
We can collect a lot of this evidence while you focus on your recovery, though some will require showing up to appointments and depositions on your part.
Can You Settle After Insurance Denies Your Workers’ Comp Claim?
Many Workers’ Compensation claims settle after an initial denial. The insurance carrier’s denial is not the final say on the matter, and our lawyers can file before a WCJ and continue to negotiate and try to settle with the insurance carrier.
If your case settles, they usually pay you everything they would pay over time in one lump sum. The WCJ usually needs to sign off on this settlement before you can end the case this way, but it is a very common way to resolve claims.
Call Our Workers’ Compensation Lawyers in Pennsylvania Today
For help with your potential claim or help fighting a denial, call Cardamone Law’s Fort Washington, PA Workers’ Compensation lawyers at (267) 651-7945.
