After you sustained a workplace injury or developed a work-related condition, you may be relying on receiving Colorado workers’ compensation benefits. Unfortunately, some injured workers receive a claim denial instead.
If you receive a denial, it is important to understand the reasons this can happen. In some cases, you may be able to appeal the decision.
Some denials happen because of formalities. Some people do not submit their claims on time or leave out important documentation. This is just one reason to be mindful of filing requirements when you put your claim together.
Unrelated to employment
Another common reason is that the insurer does not believe your injury or condition relates to your employment. Common findings include that the injury was pre-existing, that you were not a covered employee or that the injury had nothing to do with your employment.
In some cases, insurers may allege fraud. They may believe the worker purposely caused the injury or that the injury is not as bad as claimed. Insurance companies are often very vigilant about ascertaining the facts of a case. In addition to perusing medical records closely, the company may schedule an independent medical examination. Sometimes they may even have you followed to see if you are performing activities your claim says you are unable to.
In other cases, an insurer that approves benefits may suspend or cut them under certain circumstances. One common reason this happens is that the worker does not comply with his or her treatment regimen. It can be hard to show up to regular appointments, especially if you face transportation problems or a packed schedule; however, doing so is vital to maintaining benefits. Likewise, do not just stop taking medications because they produce uncomfortable side effects. Instead, talk to your doctor about possible alternatives.