11 Reasons a Workers' Comp Claim Might Be Denied

Getting hurt or sick because of your work isn’t an ideal situation, but your employer’s workers’ compensation should cover the cost of your medical bills and some of your lost wages while you recover.

The issue is that filing a workers’ comp claim isn’t always a simple process and there are multiple reasons why the insurance company could deny your claim. Here are some common reasons you might get denied when trying to get workers’ comp coverage.

1. You didn’t tell your employer about your injury.

You can only qualify for work workers’ comp if you report your injury to your employer within a certain amount of time. While many states give you 30 days to report a workplace incident, several only give you a few days. The onus is on you to know how long you have to report the injury.

To see how long you have to tell your employer — and whether you need to give written notice — check out this state reporting overview.

2. You didn’t file a claim in time.

After telling your employer that you got hurt or became ill, you also need to make sure a workers’ comp insurance claim is filed in time. In a lot of states, your employer is the one who files the claim but you may still be able to do it yourself. Either way, you need to stay on top of it. If you don’t file within a certain amount of time, you lose access to benefits.

Almost all states give you at least one year to file a claim but Nevada, for example, requires that workers’ comp claims get submitted within 90 days. Here’s a state-by-state look at filing deadlines for workers’ comp.

One thing to note here: If your employer is the one that fails to meet the filing deadline and your claim is denied, you may be able to appeal the denial. A workers’ comp lawyer can help you understand your options and fight for benefits.

3. You never stopped working.

Workers’ comp benefits are only available when you need to miss work because of your injury. If you get hurt or sick but never stop working, you can’t get benefits. Each state has its own waiting period before workers’ comp benefits start, but you generally need to miss work for three to seven days.

Similarly, if your workers’ comp doctor or treating physician approves you for light-duty work but you return to your normal job or work too much in other jobs, the insurance company could deny your claim or end your benefits.

4. Your injury or illness didn’t happen on the job.

One key thing for a workers’ comp claim is that your injury happened in the course of your job, even if it didn’t happen at your workplace. So, for example, driving into the office before your workday starts isn’t covered but an offsite meeting with a client is covered.

This part of workers’ comp is big because if your employer or their insurance company have any reason to believe you weren’t engaged in work duties, they may very well deny your claim.

If possible, write down or document exactly what you were doing when the injury happened so that no one can claim it wasn’t done on the job. The sooner you can document the accident, the fresher your memory of the details will be.

5. You were doing something you shouldn’t have been.

To be clear, workers’ comp is a no-fault system. Even if you got hurt by making an honest mistake, you will still get coverage.

But the insurance company will deny your claim if it can prove that you got injured or sick because you were being neglectful, breaking the rules, or ignoring workplace safety protocols.

So if your workplace injury happened because you were messing around with a coworker or using company equipment improperly, you’re going to have a hard time getting workers’ comp benefits. Or if you got injured driving a forklift into something because you were scrolling your phone behind the wheel, the insurance company will almost definitely deny your claim and cite negligence.

Learn more about injuries that qualify for workers’ comp.

6. Your claim is for a preexisting medical condition.

You can get workers’ compensation benefits if a workplace incident worsens a preexisting illness or injury. Similarly, you can get benefits for a repetitive-use injury that results from doing the same motion over and over. If you already have back pain, for example, and you need to unload heavy boxes from a truck, aggravating your back problem, you can likely get benefits.

That said, the insurance company may use your preexisting condition as grounds for denial. It could make the argument that you’re filing a claim for a condition that already exists, independent of what you did at work.

You’ll need to definitively prove that something happened at work to make your preexisting condition and its symptoms worse. This is another case where getting a workers’ comp lawyer can help. An experienced lawyer has seen this situation before and will know how to challenge the insurance company and prove that you deserve benefits.

Related: Situations When You Should Hire a Workers’ Comp Lawyer

7. You received out-of-network medical care.

Your employer’s insurance company generally wants you to get medical care through a doctor they’ve approved. This gives them some level of control and, in their eyes, eliminates the possibility that the medical pro will be biased in your favor.

In some states, you’re required to use an in-network doctor. In Georgia, for example, provided your employer has met certain requirements, you have to see someone from their chosen “Panel of Physicians.” Similarly, in California, unless you predesignated your personal doctor to treat you for workplace injuries, you usually need to see someone in your employer’s Medical Provider Network (MPN).

If your state requires you to see a physician in your employer’s network, any care you get outside of that won’t be covered and could result in the insurance challenging or denying your claim.

8. Your job isn’t covered by workers’ compensation.

Not all types of employees are covered by workers’ comp insurance. Full-time and part-time employees are nearly always covered. If your employer withholds taxes from your paychecks, you should be eligible for benefits.

You most likely aren’t covered and will have your claim denied if you are one of the following:

• Independent contractor

• Freelancer

• Consultant

• Gig worker (including Uber, Grubhub, and DoorDash drivers)

• Volunteer

• Temporary worker

That said, some states have exceptions. In California, for example, seasonal workers qualify under their employer’s insurance. And in New York, volunteer firefighters get workers’ comp coverage.

It’s also possible that your company mischaracterized you as a consultant or independent contractor, but you meet your state’s rules to qualify as a covered employee for benefits. If you think you should be classified as an employee but your company argues you aren’t, a good workers’ comp lawyer can help you appeal a claim denial.

Read more about how to find a good workers’ comp lawyer.

9. You filed your claim after leaving your job.

Once you leave a job, filing for workers’ compensation becomes difficult if not impossible. The insurance company may argue that since you took another job, your condition must not have been bad enough to keep you out of work. Your former employer also may not be cooperative.

You could still qualify assuming you reported the injury in time, missed enough work time, and filed a claim before the deadline. But professional help from an experienced workers’ comp lawyer can really help.

Keep in mind that it’s illegal for your employer to fire you in retribution for reporting your injury or filing a workers’ comp claim. If you were fired because of your claim, talk with an employment lawyer because you may have a wrongful termination case.

Further reading: How Much Does a Workers’ Comp Lawyer Cost?

10. There are inconsistencies in your claim.

The explanations you give to your employer, your doctor, and the insurance company need to be consistent. If the insurer thinks that your story doesn’t add up or that you aren’t telling the truth about your injury, it will probably deny your claim.

Some examples of inconsistencies that insurance could look for include giving different explanations for how, when, or where the accident happened. Insurance companies also put a lot of stock into a treating physician's reports, so it will raise suspicion if the injuries you say you have aren’t consistent with a doctor’s report.

11. You failed a drug or alcohol test.

Workers’ comp doesn’t cover injuries that result from breaking workplace rules or the law. So if your employer tests you for drugs or alcohol after a workplace incident and that test comes back positive, it gives them grounds to deny your claim.

This point is especially worth calling out since some drugs, like marijuana, are becoming legal in certain areas but not everywhere and not at the federal level.

Get legal help if your claim was denied

A lot of workers’ comp claims get denied on the first go-around. If your claim was denied, you don’t have to give up. An experienced workers’ comp lawyer will know your local rules and can help you appeal for the medical care and payments that you need to recover.

A workers’ com lawyer doesn’t charge anything upfront and you won’t have to pay anything they help you get benefits or a settlement. Atticus can connect you with a qualified lawyer who will treat your case like a priority. Start with this quick workers’ comp quiz, and then a member of our team will reach out to learn more about your situation and match you with a lawyer.

Find a local workers' comp lawyer