Protect your workers’ comp claim by watching out for these denial tactics
If you’re hurt on the job in Georgia and you file a workers’ compensation claim, your medical treatment is supposed to be covered, and you should start receiving benefits for your lost wages while you can’t work.
But insurers and employers often don’t want to pay out money after a work accident, so they look for any reason they can find to reject claims, even if they’re valid. In this article, we’ll discuss some common defenses insurers use to unfairly deny workers’ comp claims and explain what you can do to stop them.
If you’ve been injured at work in Georgia and your employer or their insurance company isn’t playing fair, reach out to Gerber & Elkins to schedule a free consultation with one of our experienced work injury attorneys in Thomaston, Dalton, Athens, or Atlanta. We can help you get the workers’ comp benefits you’re owed.
Tactic #1: Failure to give proper notice
Typically, you need to give your employer proper notice before filing a workers’ comp claim. You usually need to provide notice within 30 to 90 days after you’re injured if you plan to file a claim. This way all of the necessary paperwork can be gathered together and presented to your attorney, the insurance company representing the employer, or the court—depending on whether or not the claim can be handled in a mediation setting.
A common defense that employers use is that you didn’t give proper notice or that you informed the employer about a claim well after the injury occurred. Any notice that’s given should be done in writing so that there is documentation with a date and the details of the injury as well as why you’re seeking compensation. It’s also a good idea to give a copy of the notice to your attorney and your doctor so that more than one person knows of your intentions.
Tactic #2: Missed deadlines
The statute of limitations for filing a claim is usually different in each state. In Georgia, you have up to 1 year after the injury to file a claim if you plan to seek compensation from the employer. This is separate from the length of time that you have for informing the employer about your injuries, which is 30 days. If you’ve been exposed to a chemical and develop an illness, then the statute of limitations may be extended.
Your employer could use the defense that you waited too long to file a claim and therefore should not be entitled to any kind of workers’ compensation settlement. This is when any documents with a date will be beneficial so that there is proof that you did in fact file a claim within the established timeframe.
Tactic #3: Outside the course and scope of employment
Your employer or the insurance company could claim that your injury occurred outside the course and scope of your job. Or they could claim that you were not on the job when the injury occurred. An experienced lawyer can help you document exactly when and where the injury happened—namely, that a work injury or accident took place on work property or while performing standard work duties.
Tactic #4: Horseplay or coworker violence
Employers also try to deny claims by arguing that the injuries resulted from violence or horseplay with another employee rather than legitimate work duties.
For example, if you get injured on Halloween because a prank goes wrong at work—like a coworker jumping out in costume and accidentally knocking you down—your employer might claim the incident wasn’t work-related.
That’s why it’s crucial to have your injury examined and documented by a doctor right away, so there’s clear proof it happened while you were on the job.
Tactic #5: Failed to seek treatment
Another common defense used to deny coverage is that the injured worker failed to seek the proper treatment right away. As a result, insurance companies may argue that the injury turned into an infection or something more severe because of a failure to receive timely treatment.
If they can prove that this is true, then you likely would not be eligible for receiving workers’ compensation. These are details that you need to keep in mind when you’re making your reports—that way there is no question when you go to court regarding when and how you were injured.
Tactic #6: Missed medical appointments
Sometimes, your employer or the insurance company might request that you go to a certain number of appointments with your doctor after being injured so that the details of your injury and treatment can be documented.
Keep in mind that you might have to visit your employer’s doctor as well in order for the company to obtain their own details about the injuries that you’re claiming. Your employer could claim that you didn’t go to your appointments—and if you didn’t, then it could mean that you aren’t as seriously injured as you have claimed. This is important for establishing the amount of monetary benefits that you could receive as well. If you’re unable to work or need to perform limited tasks, then a doctor’s note will usually be needed.
Tactic #7: Pre-existing conditions
Imagine you had a sore ankle, but then twisted it badly at work. The insurer might say your ankle pain is just the old injury, not your work accident. But if your work made the pain much worse, you can still get workers’ comp. The key is to prove how your job activity increased your pain.
Here are some tips for doing that:
- Get medical records. If you saw a doctor for your pre-existing condition, get copies of those records. They can show how bad your condition was before your work injury.
- Tell your doctor about your work accident. When you see your doctor for your work injury, be sure to tell them about your pre-existing condition. They can document how your work injury made your condition worse.
- Keep a pain journal. Write down how much pain you are in and what makes it worse. This can help show how your work activities affect your pain.
Here are some additional things to keep in mind:
- Even if you have a pre-existing condition, you may still be eligible for Georgia workers’ compensation benefits if your work injury made your condition worse.
- The burden of proof is on the insurer to show that your pre-existing condition was the sole cause of your injury.
Tactic #8: Inadequate documentation of your injury
You got hurt on the job, but didn’t go to see the doctor right away?
The insurance company might say they need more proof of your injury, like doctor’s notes or test results. Without that proof, they might deny your claim.
Here are some tips for avoiding this problem:
- Seek medical attention right away. Even if your injury is minor, it’s important to see a doctor. This will create a record of your injury and its connection to your work.
- Keep all your medical records. Get copies of all your doctor’s notes, test results, and bills. These documents will be essential evidence for your claim.
- Be honest with your doctor. Tell your doctor everything about your injury, how it happened, and how it’s affecting you. This will help them document your injury accurately.
Tactic #9: Inconsistent statements
You told your co-workers you tripped on a broken sprinkler head at work and hurt your ankle, but told your doctor you fell off a ladder.
The insurance company might say your stories don’t match up and question whether you really got hurt at work. That could make it harder to get your workers’ comp benefits.
Here are some tips for avoiding this problem:
- Be truthful and consistent in all your statements. This includes what you tell your doctor, your employer, the insurance company, and anyone else who asks about your injury.
- If you need to change your story, explain why. For example, if you initially didn’t remember all the details of the accident but later recall something new, be sure to explain why your story is changing.
- Keep a record of your statements. Write down what you said to each person about your injury, when you said it, and why you said it. This can help you if there are any questions about your credibility later.
Tactic #10: Intoxication or drug use
Georgia law (O.C.G.A. 34-9-17) allows denying a workers’ comp claim if the injury resulted from:
- Intoxication by alcohol (BAC of 0.08 or higher within 3 hours)
- Being under the influence of marijuana or a controlled substance (detectable in blood within 8 hours)
- Refusal to undergo a drug/alcohol test after the accident
Rebuttable presumptions
- Positive drug/alcohol test or test refusal creates a rebuttable presumption that the accident was caused by intoxication or drug use.
- This means the injured worker has the burden to prove their intoxication/drug use did not cause the accident.
Employer/insurer’s strategy
- Employers/insurers may try to use a positive drug/alcohol test or test refusal to shift the burden of proof to the injured worker.
- They may also argue that intoxication/drug use proximately caused the accident, regardless of other contributing factors.
Tactic #11: Lack of witness or surveillance
There’s no one to back up your story. No colleagues around, no cameras catching the incident. The insurance company might try to argue that your injury didn’t happen at work or wasn’t work-related because there’s no one to corroborate your account. They might even claim you’re fabricating the injury.
Don’t panic! While witnesses and surveillance are certainly helpful, your claim isn’t invalid without them. Here are some ways to strengthen your case:
- Detailed reporting: Report the injury immediately to your employer, following their specific reporting procedures. Don’t delay! Documenting the incident promptly, including details like where and how it happened, adds weight to your claim.
- Physical evidence: Look for any physical evidence that supports your claim. Did you tear your clothing during the accident? Is there damage to your work equipment? Gather any relevant evidence to paint a clearer picture.
- Expert opinions: In some cases, consulting an expert opinion can be beneficial. Depending on the nature of your injury, an expert might be able to reconstruct the accident based on your description and physical evidence, adding credibility to your claim.
- Medical evidence: Get prompt and thorough medical care. Document everything – your injury, initial diagnosis, ongoing treatment, and any limitations caused by the injury. Medical records are powerful evidence, especially if they consistently document the injury and its connection to work.
- Witness alternatives: Even if there were no direct witnesses, are there people who can indirectly support your claim? Colleagues who saw you working in the area before the injury, someone who noticed your pain afterward, or anyone who heard about the incident shortly after it happened. Their testimonies can bolster your case.
Remember that workers’ compensation is a “no-fault” system, meaning that employees are entitled to receive benefits for job injuries or illnesses, regardless of who was at fault for the accident.
This no-fault characteristic is a fundamental aspect of workers’ compensation, designed to protect both employees and employers in the event of workplace injuries.
In a no-fault system, an injured employee doesn’t need to prove that the employer was negligent to receive workers’ compensation benefits.
Conversely, the employer is generally protected from lawsuits filed by employees over work-related injuries. This setup streamlines the process of getting help for the injured worker, focusing on treatment and recovery rather than legal battles over liability.
These are just a few of the ways insurance companies may try to deny your workers’ compensation claim, even if your injury is valid. Be sure to reach out to a trusted workers’ comp attorney in order to fight back against these claims, and receive the maximum benefits available to you.
Contact Gerber & Elkins Workers’ Compensation Attorneys today to schedule your free consultation.
