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Why might a workers' compensation claim be denied?

Workers' compensation benefits can prove to be a critical resource for injured employees. Not only do these benefits cover eligible medical expenses, but they can also replace a portion of your wages.

As such, it can be very upsetting to learn that benefits could be in jeopardy because of a disputed claim or denial. Below, we examine some of the common reasons why disputes arise involving workers' compensation claims and what workers can do to avoid or address them.

  1. Not going to the doctor right away: This is one of the most common reasons claims are denied. The longer you wait to see a doctor, the more likely your claim is to be denied.
  2. Not reporting the injury as a work accident to the doctor: Even people who do see the doctor immediately after an injury do not always tell the doctor the truth about how the injury happened. If you do not tell your doctor that your injury happened at work, your employer may use that as a reason to deny your claim.
  3. Pre-existing conditions: If an employer or insurance company sees that an employee has been treated before for the same condition, they may use that as a reason to deny the claim. Although it is possible to claim workers' compensation for aggravation of a pre-existing condition in Illinois, such claims are often disputed.
  4. Ineligibility: While most workers in Illinois are eligible for workers' compensation benefits, there are people who do not meet the eligibility requirements. In Illinois, employees are covered by workers' compensation laws, but independent contractors typically are not. There may be disputes over the employment relationship or the person's status at the time of an accident that make a person ineligible.
  5. Details of the accident disqualify the worker: Injuries or illnesses must "arise out of and in the course of employment," in order to qualify for benefits, as noted in the Illinois Workers' Compensation Commission handbook. If an accident happened away from work, for instance, then it may not be covered. Further, benefits could be unavailable to workers who may have been under the influence of drugs or alcohol at the time of an accident.
  6. Failure to comply with procedures: Many times, denials stem from procedural errors like failing to submit proper notification in a timely manner. In Illinois, employees are required to report an injury orally or verbally within 45 days to a supervisor (notice to a coworker does not count). However, employers often have internal policies requiring even earlier notice. It is best to report your injury to your supervisor right away.
  7. Disagreement over case details: Disputes can arise if an employee and the WCC disagree on details like weekly wages, the extent of a person's disability and whether specific care was reasonable and necessary.

Should any of these lead to denied benefits, it can be crucial for workers to understand their options. Do not feel like you have to give up and accept an undesirable decision.

You can appeal decisions with which you do not agree; there are multiple levels of appeal. Generally, you will file a request for appeal, and then an arbitrator or a panel of commissioners will review the case and make a decision.

Whether you want to file a claim for benefits or an appeal, having legal counsel assist you can be valuable. Not only can legal representation help you strengthen your claim, it can also help you avoid costly missteps that could lead to delays or denials.

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