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Why was my workers' compensation claim denied?

Your workplace injury left you hospitalized or home in bed for longer than you could afford. Needing surgery, requiring physical therapy or developing an infection may have prolonged your recovery and raised anxiety in your family about how to pay the medical bills and normal expenses. Fortunately, your employer carries workers' compensation insurance, as required by South Carolina law.

Because you were counting on workers' compensation, you were shocked to receive a letter saying the insurer had denied your claim. Now you have many questions and concerns about what to do next.

Common reasons for denial

Workers' compensation protects employers from lawsuits because it pays for most injuries employees suffer in the workplace or during regular duties of the job. It is possible that your denial was a mistake, but even if it wasn't, you may be eligible to appeal the decision. Your first step is to carefully read the letter from the insurer, which explains the reasons for your claim denial. The most common factors in a workers' compensation denial include the following:

  • Not reporting the injury to your employer within the 90-day deadline
  • Failing to file your claim for coverage before two years elapsed
  • Inflicting injuries on yourself intentionally or while attempting to harm someone else
  • Not submitting enough evidence that your injury happened on the job
  • Failing to obtain medical treatment or neglecting to follow through with doctor's orders

An insurer will also deny a claim for an injury that is not compensable. For example, you cannot claim injuries if you were in an accident on your way home from work or if you slipped and fell when you went out for drinks with co-workers at the end of the day. Your employer may also dispute your claim if he or she has reason to believe that you were injured because you were goofing around on the job or you were intoxicated at the time of the accident.

Invalid denial?

If none of the above factors apply to your situation, it is possible that the insurance company unjustly denied compensation or that your employer failed to support your claim for coverage. You have the option of appealing the decision, but you have a limited time to do so. Seeking advice from an attorney who has experience with the appeals process in this state is an excellent place to start.

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