Workers’ compensation is essential for protecting employees who suffer injuries or illnesses due to their jobs. However, many claims get denied, leaving workers without the support they need.
Understanding the common reasons for these denials can help employees and employers navigate the system more effectively.
Insufficient medical evidence
One of the primary reasons workers’ compensation claims are denied is due to insufficient medical evidence. In New Jersey, claimants must provide comprehensive medical documentation proving their injury or illness is work-related.
This includes medical reports, doctor’s notes and diagnostic tests. The claim may be denied if the documentation is incomplete or does not connect the injury to the workplace.
Failure to report the injury on time
New Jersey law requires employees to report workplace injuries to their employer within 90 days. Delays in reporting can lead to suspicion about the legitimacy of the claim.
When an injured worker does not notify their employer immediately, it may be argued that the injury did not occur at work or that it is not as serious as the worker claimed. If this happens, the claim may be denied.
Pre-existing conditions
Claims may be denied if the injury is a pre-existing condition rather than a new, work-related injury. Insurance companies often scrutinize claims for signs that the injury existed before the reported incident. Workers must demonstrate that their condition was exacerbated by their job duties to counter this denial reason.
Discrepancies in the incident report
Accurate and consistent reporting of the incident is crucial. Discrepancies between the employee’s account, witness statements and medical records can result in a denial. Insurance adjusters will investigate any inconsistencies, which may lead them to conclude that the injury is not work-related or that the claim is fraudulent.
Navigating the workers’ compensation system in New Jersey can be challenging, especially when facing a claim denial. Understanding the common reasons for denials can help employees better prepare their claims and avoid common pitfalls.