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Reasons for Workers’ Compensation Denials

by | Oct 5, 2017 | Denials, Workers' Comp Benefits, Workers' Compensation

According to the New York State Workers’ Compensation Board, “Virtually all employers in New York State must provide workers’ compensation coverage for their employees (WCL§2 and 3).” So, who is covered under New York’s workers’ compensation laws? “Workers in all employments conducted for-profit. Part-time employees, borrowed employees, leased employees, family members and volunteers working for a for-profit business must also be covered under Workers’ Compensation Law,” says the Board.

Now that we know which workers are covered, are they ever denied? Yes, even “covered” workers can file a claim for workers’ compensation only for it to be denied. The question is, what are the reasons for workers’ comp denials? There are a number of reasons; for example, suppose a real estate agent was an independent contractor. The real estate agent gets into a car accident while driving clients around. Because she’s an independent contractor, she would not be entitled to workers’ compensation, even though the crash occurred while showing properties to clients.

Reasons for workers’ compensation denials:

  • Failure to provide proper notice to your employer. In New York, workers are instructed to notify their employer asap after a workplace accident, “but within 30 days,” according to the Board.
  • Filing a claim past New York’s statute of limitations for filing workers’ compensation claim. The Board warns injured workers, “Failure to file a claim or give the employer notice may result in the loss of rights to compensation.”
  • Causing self-inflicted injuries. If a worker intentionally causes their injuries in hopes of filing a fraudulent workers’ compensation claim, it will lead to a denial of benefits.
  • Injuries sustained while under the influence of illegal drugs or alcohol. While workers’ comp is technically a no-fault system, that does not apply to workers who are under the influence of drugs or alcohol when they are injured. If a worker is injured because he or she was impaired by alcohol or drugs, their claim will be denied.
  • The injuries are NOT work-related. In order for someone to have their claim approved, the injury or illness must be work-related. Injuries outside of employment do not qualify for workers’ compensation benefits.
  • Failure to receive ongoing medical care. If you fail to continue seeing a medical doctor as recommended by your healthcare provider, your benefits can be reduced or cancelled as a result.
  • The injury is not as bad as you claim it is. If you claim that your injury prevents you from working but medical evidence shows otherwise, your claim can be denied.
  • Willful negligence or recklessness. If evidence clearly suggests that you were “messing around” or engaging in dangerous horseplay, your claim can be denied.
  • The cause of injury cannot be determined. In order to process your workers’ compensation claim, it’s important to determine the cause of the injury. If the cause cannot be identified, the insurance company may contend that it was not employment-related. Often, an independent medical evaluation can help determine the cause of the injury.

Looking for a New York workers’ compensation attorney? Contact Katz, Leidman, Freund & Hermanfor a free case evaluation.