What to Do If Your Workers' Comp Claim is Denied in North Carolina

What Are the Reasons for Denying a Workers’ Comp Claim?

There are several reasons why an employer or their insurance company might deny your workers’ comp claim. Some common reasons include:

• The injury or illness isn’t work-related– Insurers might argue that your injury or illness didn’t occur in the course of your employment or that it happened outside of work hours or during a non-work-related activity since these conditions disqualify you for workers’ compensation benefits.
• The injury or illness isn’t severe enough– Insurers may argue that your injury or illness isn’t severe enough to warrant time off work or medical treatment. They may contend that you can continue working without limitations.
• The claim was filed after the deadline– Workers’ compensation laws impose strict deadlines for reporting injuries or illnesses and filing claims. If you miss these deadlines, the insurer may deny your claim on the grounds of untimeliness.
• You didn’t follow the proper reporting procedures– Failing to report your injury or illness to your employer according to the required procedures and within the specified timeframe may lead an insurer to deny a claim. Insurers may argue that your employer wasn’t given adequate notice to investigate the matter.
• Your employer disputes the extent of your injury or illness– Your employer’s insurer might try to argue that your injury is not as serious as you say it is, claiming that you’re exaggerating or misrepresenting the facts. They may argue that your work restrictions or medical treatment aren’t necessary or justified.
• Your injury occurred because of a pre-existing condition– Insurers might deny a workers’ comp claim if they believe that a pre-existing condition contributed to or caused the injury or illness. They might argue that the current injury is unrelated to your job and instead stems from your previous injury.
• There is insufficient medical evidence of your injury– An insurer might use a lack of medical documentation supporting your injury or illness as an excuse to deny your claim. They could argue that there isn’t enough evidence to prove the injury or illness is work-related or severe enough to warrant compensation.
• You engaged in fraud or misrepresentation– Insurers can deny a claim if they suspect fraud or misrepresentation. This could include cases where the worker provides false information about the injury or illness, exaggerates the extent of the injury, or fabricates a work-related accident.
• You were intoxicated or under the influence of drugs– Workers’ compensation laws protect employers from liability for injuries caused by intoxication. Your employer’s insurer might deny your claim if it believes drug or alcohol consumption contributed to your injury.
• You did not comply with medical treatment– Failing to follow prescribed medical treatment or attend scheduled appointments may result in a claim denial. The insurer might argue that your non-compliance is hindering your recovery and that you’re not taking the necessary steps to improve your condition.

Some employers and their workers’ compensation carriers try to deny valid claims on any grounds they can think of. They hope that by denying your claim, you will give up. But you don’t have to. You have the right to appeal your claim and assert your rights under the workers’ compensation system.