Understanding Medical Denials for Workers’ Compensation Claims

Attorney Mark Rufo PC

Workers’ compensation claims pose complex questions about your eligibility based not only on the circumstances but also the medical information. Many workers’ compensation claim denials happen for medical reasons. If you receive a medical denial, you can request a reconsideration hearing.

Understand the most common reasons for medical denials so you can prepare for your hearing.

Pre-existing condition

When you have a pre-existing medical condition, that condition could disrupt your workers’ compensation claim. The insurance carrier might deny the claim on the assumption that your condition contributes to the injury. You might need a medical expert to attest that there is no connection between the two.

Incomplete medical records

Part of the review process for the claim includes a comprehensive review of your medical records. When the records supplied to the claims adjuster lack sufficient evidence for the claim, the insurance carrier denies it. Make sure that you supply comprehensive records as part of the reconsideration process to improve your chances of approval.

Video evidence contradiction

Workers’ compensation insurance carriers may retain the services of private investigators if they suspect a fraudulent claim. If video evidence from a private investigator shows you doing something that the injury should prevent, that evidence may lead to denial. You can contest the video with context that explains what occurred.

Understanding common medical denials for workers’ compensation claims makes it easier to contest that denial during your hearing. Review the reason for your denial and gather as much information as you can for a chance to overturn that decision.