Ever wondered about the fate of most workers’ comp claims and how many workers comp claims are denied? The reality might surprise you. A significant chunk – precisely 7% – finds itself on the chopping block, initially denied.
This percentage plays a crucial role in understanding why ensuring your claim’s success isn’t just a walk in the park but more like navigating through a minefield without stepping on any explosives. With such odds, knowing how to navigate this tricky terrain becomes paramount.
Understanding Workers’ Compensation and Its Importance
In the United States, the total cost of disabling workplace injuries is more than $58 billion a year. Workers’ compensation insurance is the primary way that employers provide benefits to workers who are injured on the job. This guide will walk you through the nuts and bolts of workers’ compensation, shedding light on typical injuries that lead to claims and how many workers comp claims are denied each year.
For the past five decades, it’s been all hands on deck with government bodies and businesses teaming up to make our workplaces much safer spots. In fact, injuries and illness have dropped significantly in that time, declining from 10.9 cases per 100 full-time equivalent (FTE) workers in 1972, to just 2.8 incidents per 100 FTE workers in 2018, a 75% decrease.
Despite these huge gains, workplace injuries and illnesses are still common, and they can be costly for workers and employers alike. A recent study found that workplace injuries cost companies $1 billion a week.
The primary way that injured workers pay for medical treatment and other expenses is with workers’ compensation insurance. In this guide, you’ll learn about the most common work-related injuries associated with claims, how many workers compensation claims are denied, and how Site Visibility can help prevent injuries before they happen.
What are the most common injuries that lead to workers comp claims?
Workers’ compensation, commonly shortened to “workers’ comp,” is insurance that provides benefits to workers who get injured or become ill as a result of their jobs. Workers’ compensation benefits often include cash to replace lost wages, as well as pay for the cost of medical care and rehabilitation services, if needed.
In the U.S., workers’ compensation insurance is primarily administered by individual states, though there are programs managed by the U.S. Department of Labor for federal employees and certain groups, such as longshore and harbor workers. At the state level, individual employers are mandated to pay premiums to private insurers, who administer and pay out benefits. Texas is the only state that does not require employers to have workers’ comp insurance.
Each state has an agency that oversees their workers’ comp program, and claims requirements and benefits vary greatly by location. Called workers’ compensation boards, these organizations ensure that employers provide the required coverage and intervene when disputes arise.
What percentage of workers’ comp claims are denied?
In 2019, the top 10 causes of serious, nonfatal workplace accidents amounted to $49.18 billion in direct workers’ compensation costs. These are the top five types of workplace accidents and the total cost of workers’ comp claims for each:
- Overexertion involving outside sources: This work injury occurs when employees lift, push, pull, carry, or throw objects, often when they are too heavy. These injuries cost $12.63 billion in workers’ comp per year.
- Falls on the same level: At job sites, trips and slips are more common—and costly—than falling off a roof or ladder. Falls on the same level-type injuries cost $10.26 billion in workers’ comp every year.
- Struck by an object or equipment: A tree that hits a logger, a construction worker that gets hit by debris from a collapsing wall—these are two examples of “struck-by” injuries. Objects or equipment that fall, roll, slip, and swing can pose a serious threat to workers, and they cost $5.66 billion per year in worker’s comp.
- Falls to a lower level: Even if falling from a ladder or roof isn’t as common as tripping, the “falls to lower level” injury category is still a major cause of workers’ comp claims, costing just over $5 billion per year.
- Other exertions or bodily reactions: This category includes injuries that are caused by repetitive motion or awkward posture, such as crouching, crawling, lifting, or using tools that cause hand or muscle strain. These injuries lead to a little over $4 billion in workers’ comp claims each year.
Top reasons why workers’ comp claims are denied
A workers’ compensation case goes through a rigorous review process and insurance companies end up denying a significant portion of them. According to the most recent study with comprehensive data, 7% of workers’ compensation claims are initially denied, though these percentages can vary by state. In Oregon for example, 12% of workers’ comp claims are denied.
Here are some common reasons an insurance carrier will deny a workers’ comp claim:
- The injury was not reported in time.
- The injury is not compensable.
- There is a dispute about whether the injury is work-related.
- Insufficient medical evidence to support the claim.
- Discrepancies between accident reports and medical records.
- Failure to attend an independent medical exam.
- The condition is pre-existing and not related to employment.
The Impact of Preexisting Conditions on Claim Approval
How pre-existing conditions affect your claim
Insurance companies will often look for reasons to deny a claim if you have a pre-existing condition, even if your current injury was clearly caused by a workplace accident. They may argue that your injury was caused by the pre-existing condition rather than your job duties. This is why it’s so important to disclose any pre-existing conditions to your doctor after a work injury and explain how your symptoms differ from before the accident.
Tips for filing a successful claim with a pre-existing condition
- Be honest and upfront about your medical history.
- Provide medical records showing your condition was stable before the work injury.
- Have your doctor document how the work injury aggravated or accelerated your pre-existing condition.
- Demonstrate how your current symptoms and limitations are different than before.
- Consult with a workers’ comp attorney who can help prove your case.
Navigating the Appeal Process for Denied Claims
Steps to appeal a denied workers’ comp claim
If your workers’ comp claim is denied, you have the right to appeal the decision. The appeals process varies by state but generally involves these steps:
- File a formal appeal with the workers’ comp board.
- Attend any hearings and present your evidence.
- Receive a written decision from the board.
- If you disagree with the hearing decision, file a further appeal to a higher level of review.
- Consider hiring a workers’ comp attorney to assist with your appeal.
Importance of meeting deadlines in the appeal process
When appealing a denied workers’ comp claim, meeting deadlines is crucial. If you miss an appeal deadline, you could lose your right to challenge the denial.
Deadlines vary by state but are typically between 30-90 days from the date you receive the denial notice. Be sure to carefully read your denial letter and note the exact deadlines for appealing.
The Role of an Attorney in Workers’ Compensation Cases
When to consider hiring a workers’ compensation attorney
While it’s possible to handle a simple workers’ comp claim on your own, there are situations where it’s advisable to hire an attorney, such as:
- Your claim is denied and you need to appeal.
- Your permanent disability rating is disputed.
- You have a pre-existing condition.
- Your ability to work is affected.
- You’re not receiving the proper medical treatment.
- You’re being pressured to return to work too soon.
An experienced workers’ comp attorney can gather evidence, negotiate with the insurance company, and represent you at hearings to protect your rights.
How an attorney can increase your chances of claim success
Studies have shown that hiring a workers’ compensation attorney can significantly increase your chances of having your claim approved and receiving higher compensation amounts. An attorney understands the complex workers’ comp system and can help you avoid mistakes that lead to denials. They can also make sure you get all the goodies the law says you should, like your missed paychecks, medical care, disability bucks and even training for a new job if needed.
FAQs in Relation to How Many Workers Comp Claims Are Denied
How long do most workers comp settlements take?
Settlement times vary, but expect anywhere from several months to two years. Patience and detailed documentation speed things up.
Why is workers comp so hard to deal with?
Navigating laws, paperwork, and insurance company tactics can be complex. It’s often a game of persistence and precision.
What is the most common workers comp claim?
The top spot goes to strains and sprains from lifting or overexertion. Always lift with your legs.
What is the most you can get from workers comp?
Your payout depends on injury severity, wages before injury, and state law caps. There’s no one-size-fits-all answer here.
Conclusion
In our journey today, we’ve peeled back layers to uncover not just numbers but stories behind those figures regarding how many workers comp claims are denied. It’s far from being all doom and gloom; it’s more akin to getting that one puzzle piece which doesn’t seem to fit at first glance. But with patience and perhaps some rejigging – voila! – it finds its place perfectly.
The world of workers’ compensation is complex, yes, but now you’re armed with knowledge. Remember, every denied claim isn’t an end but potentially the start of a new chapter where justice may just be around the corner—armed with facts and possibly an expert attorney by your side; marching towards that appeal could turn tides in your favor.
