Worker compensation insurance carriers love to find reasons to deny workers compensation benefits.  Here are the top 10 trending reasons to deny benefits.

1. Not Reporting the Work Injury Promptly
   In Wisconsin, while there is no definitive deadline to report a work injury to your employer, late reporting will lead insurers to question the validity of the claim.  Insurers fail to see that injured workers are often scared to report an injury for fear of repercussions.  Moreover, injured workers often wait on reporting an injury in the hope that it will heal or is not serious enough to report.
2. Supportive Medical Documentation is Lacking
   A Wisconsin workers compensation injury will be denied if there is insufficient medical evidence linking the injury to the workplace exposure or incident.  For example, if the medical treatment records do not mention that the accident or injury occurred at work then the reviewing adjuster will consider this a red flag when determining whether to accept or deny the claim.   It is important for the injured worker to consistently describe to their medical providers the details of how the symptoms/injury occurred so that it is formally documented in the medical records.
3. A Factual Dispute Exists as to Whether the Injury is Work-Related
   A workers compensation insurance company can argue that the injury did not occur because of work-related activities or unrelated to the job if it is not factually supported with details and/or witnesses.  For instance, if you fall and get injured at work but you then report that you have no idea how or why you fell then the claim will likely be denied.  Facts need to support that the injury occurred because the worker was in a zone of danger, such as water or oil on the floor where the worker fell acting as a trip hazard.  It is not enough for the injured worker to claim that because they fell and injured themselves then the claim should be compensable.  Something about the conditions of the employer’s premises had to have put the injured worker in a place of danger.
4. Similar Pre-Existing Injury/Condition
   A workers compensation injury claim will always get denied if the injury or symptoms can be attributed to a pre-existing condition.  For example, back pain documented in medical records weeks, months, and even a year prior to the work injury will allow the insurance carrier to claim that later back injury occurring and reported on the job was pre-existing and not related to the work.
5. Violation of Company Policy
   If the injury occurs because the worker failed to use a safety device then compensation can be reduced for the employee’s failure to obey a reasonable safety rule.  Also, no compensation will be paid if the employee violates an employer’s policy concerning drugs or alcohol use if the violation is causal to the employee’s injury.
6. Injured Worker Fails to Cooperate
   When an injury occurs, the workers compensation carrier must do an investigation into the details of the injury.  Such an investigation requires employee cooperation.  The employee will be asked to give a recorded statement detailing who, what, where, and why details of the injury.  They will also be asked to sign medical authorizations so that the insurance carrier can get access to their medical records.  Moreover, they must keep the insurance carrier updated on changing physical restrictions and whether the employer is providing accommodating work.  If an injured worker fails to cooperate and communicate with the insurance carrier, then their uncooperativeness will be used against them to suspend or deny benefits.
7. Evidence of Injury is Lacking or Insufficient
   The last thing an injured worker thinks about after a workplace injury occurs is documenting it.  Most injured workers know to report their injury to their supervisor/employer but many do not know that timely details should be recorded and saved.  To substantiate the injury, pictures of the scene, equipment, work conditions, witnesses’ names and contact information should be gathered and saved.
8. Missed Deadlines for Filing a Workers Compensation Injury Claim
   Workers compensation claims typically have a statute of limitations.  Wisconsin Statute Sec. 102.17(4) currently provides that a Hearing Application for benefits may be filed within 12 years after the last payment of primary compensation by the insurance carrier for an occupational injury.  The time limit is 6 years for a traumatic injury (occurring after March 2, 2016).  Missing such filing deadlines to toll the claim can lead to an automatic denial by the Department of Workforce Development – Division of Hearings and Appeals.
9. Employee Classification Issues
   In Wisconsin, if a worker is classified as an “Independent Contractor” versus an Employee then they may not be eligible for workers compensation benefits.  However, classification of such is tough because nine statutory requirements must be met in order to be classified as an Independent Contractor.   Mays Law Office encourages any injured worker who has been denied benefits because of independent contractor status to contact our office to discuss if your employment truly falls under the nine requirements.
10. Inconsistent or Conflicting Statements
    Workers compensation insurance companies love to find inconsistencies or discrepancies between the worker’s account of the injury.  Finding such allows them to deny benefits.  Adjuster’s dig through medical records looking for such discrepancies.  They seek out witnesses hoping to contradict the injured worker.  Finding such allows them to point to such inconsistencies as a basis for their denial.

Outsmart Workers Compensation Insurance Companies – Tips to Prevent Denial of Work Injury Claims:

• If you are injured, then report it immediately to a supervisor.  Document such reporting with an email or text message.  Document the injury by taking pictures, keeping notes of the details, and talk/text to witnesses to save their statements.
• Know and follow your employer’s protocols.  Timely complete an Incident Report and keep a copy of it or take a picture of the report with your telephone.
• Seek medical attention immediately, give your medical provider a detailed explanation of how the injury occurred and the symptoms you suffered.  Keep a journal of your medical treatment as to dates and providers.
• Provide consistent explanations of how the injury occurred to your employer, the insurance carriers, and medical providers.
• Consult with an experienced workers compensation attorney, like Mays Law Office, to navigate the claims process.  Mays Law Office offers free consultations.

Unfortunately, there is a trend in the insurance industry to deny workers compensation claims. Here’s why:

1. Profit Motivation
   Workers’ compensation insurance companies are for-profit business entities. It is logical to assume that paying out fewer benefit claims allows them to retain more revenue thereby increasing their profitability.
2. Reduced Payouts
   An insurance carrier that denies benefit claims, even if only temporarily, is able to delay and often completely eliminate the need for payouts.  Insurance carriers know that a certain percentage of injured workers will not fight/appeal for benefits after an initial denial.  The intimidation of being contentious or hiring a lawyer is too stressful for many injured workers.  This tactic allows workers’ compensation insurance companies to invest and grow their reserves while reducing their immediate liabilities.  Mays Law Office encourages Wisconsin injured workers who have been denied benefits to call for a free consultation.  They will be treated with respect and honesty, and safe from intimidation.
3. Deterrence of Fraudulent Claims & Negotiation Strategy
   Workers compensation insurance companies want to send a strong message to employees to not file questionable workers compensation claims. Strict scrutiny of claims discourages fraudulent or exaggerated claims, which would otherwise lead to significant financial losses. Denials are often strategic. By denying a claim initially, worker’s compensation insurers intimidate, and pressure injured workers who are financially destitute into settling for a lower amount than they might otherwise receive. Readily approving injury claims set a precedent to other employees and encourages more claims of a similar nature. Denials send a message to other employees that claims will be rigorously evaluated and defended against. Attorney Lisa Pierobon Mays will not be intimidated; she will take on any Wisconsin employer who unjustly denies workers compensation benefits to an injured worker.
4. Policyholder Retention
   Employers hate work injury claims because it can affect their insurance rates.  Some employers who purchase workers compensation insurance may even seek out certain carriers that keep their premiums low. Denying claims and minimizing benefit payouts helps insurers manage the loss ratios that affect premiums.
5. Legal and Administrative Costs
   While denying benefit claims can lead to legal litigation, workers compensation insurance companies have significant legal resources.  They have attorneys on speed dial that they refer such litigation to.   They see the cost of litigation as worthwhile because of the savings from not paying out the claim.

Workers compensation insurance companies are betting that for every 5 injury claims they deny, only 2-3 will hire an attorney to recover benefits.  They are relying on the savings of those injured workers that did not fight for benefits.  Moreover, in Wisconsin, injured workers who have only unpaid medical treatment expense in dispute are likely left without legal defense because attorneys in Wisconsin are precluded from taking any attorney fee on the recovery of just medical bills.  With this, an injured worker is looking for an attorney who will represent them for free.  Most attorneys will not take on a file without some compensation for their time.  So, Wisconsin injured workers in this situation are left without representation due to this statutory regulation in our workers compensation law.

While it is true that workers compensation insurance companies are financially incentivized to deny or limit claims, they are also bound by legal obligations to act in good faith.  If they do not, they will be faced with penalty claims that give the injured worker additional monies.  Mays Law Office has been very proactive in keeping insurance carriers legally honest in their handling of claims.   Attorney Lisa Pierobon Mays will not hesitate to file a penalty claim against any employer or insurance carrier if benefits clearly should be paid.

Wisconsin injured workers who feel their claims are unjustly denied should consider consulting with an experienced workers compensation attorney, like Attorney Lisa Pierobon Mays, to challenge the decision.  Free consultations are offered at Mays Law Office.  Check out Mays Law Office’s 5-Star Google Reviews from actual past clients – positive reviews and results are the best indicator of a good attorney.