There are many reasons why insurance companies deny workers’ compensation claims. The most common ones are the injury does not fit the specific definition of a covered “injury by accident”, it did not occur while on the job, the claimant had a preexisting condition that wasn’t related to work, or the worker failed to file the claim on time without a valid excuse. Insurance companies will look for any reason to deny a claim.
In some cases, however, the claims are too bizarre to be believed. These examples show that truth is stranger than fiction:
- He’s no Spider-Man – In 2015, a firefighter and emergency medical technician working in Siloam Springs, Arkansas, sustained a fracture after jumping out of bed during his shift. The accident happened at around 2:00 a.m. when the startled victim dreamt that spiders were crawling all over him. The injury required surgery, but the firefighter’s claim was denied since he couldn’t prove that the injury was related to his work.
- Pipe dreams – A pipefitter from Mississippi found out the hard way that it doesn’t pay to act like a child on the job. The victim was reminiscing about his childhood and decided to climb a tree together with a coworker. He reached a height of about 25 feet but fell when one of the branches snapped. The claimant broke five ribs and injured his spinal cord. He was never compensated for acting like a kid.
- Bad joke – This worker patched tires in a shop with special glue. While fixing a tire, the claimant decided to pull a prank on his coworker and lit the can of glue that the latter was holding. Trouble is, the glue was flammable and it exploded when the surprised coworker dropped the can. The two sustained severe burns but none were compensated for the cruel joke.
In the above examples, the workers’ compensation claims were rejected because they had no legal basis in the particular states where the accidents occurred. Keep in mind every State has its own workers’ comp laws, so North Carolina has its specific set of rules for work injuries. Even the above cases may have different results in different States. However, in many cases, insurance companies simply don’t want to pay the claims — even if they are valid — and will look for every reason to reject them.
In a perfect world, this shouldn’t happen. Unfortunately, we don’t live in one, even in beautiful North Carolina! The sad truth is that defense attorneys, adjusters, independent medical examiners hired by employers, reviewing physicians, and claims service specialists are always looking for inconsistencies and deficiencies in the injured worker’s medical records to deny claims.
Rejection can be painful, particularly when a worker has a real injury and badly needs help. To avoid this fate, consider the following to make your workers’ compensation claim valid:
- Stick to the truth – Your work injury history is important, so get it right the first time. You must give details about how the accident occurred. Tell the attending physician what really happened and be consistent. Don’t taint the truth with your own rose-colored version. Doing so will only produce an incomplete and inaccurate record. Worse, a bad record may take years to correct, greatly affecting your credibility. It’s always better to speak to a lawyer before giving statements about your injury to an insurance company.
- Make sure everything is recorded – Your work injury history is normally used as a reference by emergency room, urgent care, or occupational health facility physicians. Since you’re not the only patient they have, these people may be in a hurry at times and not always record what you say. Make sure that your injury is heard right and properly recorded to avoid mix-ups and misunderstandings later.
- Tell the whole story – Describe in detail your activities prior to your work injury or before the onset of pain. If you were lifting something heavy or doing repetitive work, tell the physician. Physical activity before the actual onset of pain is often the cause of the injury.
- Describe how you feel – Be sure to describe each and every injury sustained at work. In many cases, an injured person will remember only the most painful injuries. Don’t leave out lesser problems because they can become big ones later. This often happens in back and neck injuries when the injured worker fails to tell the doctor that other areas of the spine were also affected. Omitting this can create inconsistencies in your medical record and affect your workers’ compensation claim.
- Never sign anything without reading it – Before signing a workers’ compensation claim application, check that everything is in order. Don’t be rushed into submitting an incomplete form by the medical provider, employer, or managed care organization (MCO). Check if the form contains an accurate description of your injury and lists all body parts involved. This is for your own protection because some employers, MCOs, and medical providers deliberately limit the information or include inaccurate information on the form to reduce the scope and cost of the claim.
Your best defense against faulty forms is vigilance. Double-check everything before filing your claim, and consult a board-certified workers’ compensation specialist like Maggie Shankle of Shankle Law Firm, PA. Maggie belongs to an elite class of individuals who have undergone rigorous training and testing, and know a lot about workers’ compensation law. Consult her today to get what you deserve.