Most Common Reasons Workers’ Comp Claims Get Denied in Virginia

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Workers’ compensation insurance is a concept built around protecting employees who get injured or sick because of their work. Other than some very few exemptions, by law, almost all employers in Virginia are required to provide this coverage for their employees.

Some of those exceptions include businesses with fewer than three employees, agriculture sector businesses that have fewer than five employees, domestic services operations, and churches, just to name a few. You can almost bet that your business is required to provide it under Virginia law.

In Virginia, workers’ compensation does not operate by placing fault on any party. As long as an employee was injured or got sick while working for you, then they can receive compensation and benefits from the program.

It doesn’t matter if they caused the accidents themselves, or if your substandard safety policies were to blame. This protects both the employee and the employer since with no-fault coverage the employee is not legally able to file a lawsuit against their employer.

The employee can get benefits without having to go through the hassle of filing a lawsuit and proving that someone was negligent. While this might imply that it’s then easier for workers to get their benefits, this isn’t always the case. Employers purchase their workers' comp policy in Virginia from an insurance provider.

The provider is the entity that decides whether or not a workers’ compensation claim is valid and that benefits will be provided. Here are some of the most common reasons why workers’ comp claims get denied in Virginia.


The Injury Wasn’t Sustained at Work

The Injury Wasn’t Sustained at Work

The main purpose behind workers’ compensation is to protect workers if something happens while they are at work. If an employee is out and about and gets hit by a car, that is not an injury that happened while on, or because of the job. The insurance company will most likely deny a claim of this sort. However, it is not always simple to determine what is, “at work” and what is not.

For example, we can use the above scenario. During an employee’s lunch break, you ask them to pick up coffee for everyone at the job site. They give you money, and off they go. They are technically not on the clock and not performing normal work duties. However, they are then hit by the car and suffer serious injuries.

In this situation, just because the employee was technically not getting paid for that time, it does not mean that they are not eligible for compensation. Their boss asked them to perform the task, and they were injured doing it. This should be a valid claim.


The Employee Does Not Provide Notice to the Employer

If an employee is injured while on the job, they should notify their immediate supervisor immediately. For workers’ compensation coverage, they must provide it within 30 days. However, if they were to take that long, it can muddy the waters as to the facts of the case and make it more difficult for them to claim the injury happened at work.

The insurance company could claim that they were injured on their off time and only waited so long to report it because they weren’t sure they qualified. Employees should also keep a copy of any records of visiting hospitals or medical treatments to provide as proof for the insurance company.


The Employee Does Not File A Claim Before the Deadline

Let’s say an employee gets injured at work. They are not able to work for several months, but they have savings and do not make a workers’ compensation claim, thinking they can do so when they are healed and ready to focus on it.

Once they are healthy and back to work, they do not get around to it. By the time they do, two years have passed since the time of the injury. If they do not file before two years, then they will be rejected for compensation. That is a hard deadline that means automatic disqualification.


No Medical Proof That There Was An Injury

If there is no medical proof that there was an injury, then an insurance provider will not pay out benefits. The employee must seek medical attention for their injury or illness. They cannot just claim that they were hurt without providing any evidence of it. They should also seek treatment promptly. This is especially important with injuries that aren’t as obvious as others.

If they suffer from a repetitive stress injury, such as a bad back from lifting things on a job site, then there is no visible evidence of injury. However, documents from a health practitioner will serve as the evidence that the insurance company requires.


Intoxication 

Intoxication 

While workers’ compensation coverage in Virginia is considered no-fault, there is one exception. If the worker is deemed to have been under the influence of alcohol or drugs at the time of the accident, then they may be denied compensation.

It is illegal in Virginia to test workers for drugs and alcohol unless there is reason to believe it contributed to the incident. If intoxication was not a contributing factor to the injury, then the employee might be successful with their claim. However, it can be very hard to prove this point.


Pre-Existing Conditions

Insurance providers can also deny workers’ compensation claims if the employee was deemed to have a pre-existing condition. For example, if the employee claims that tendonitis in the wrist has caused them to be unable to work, they will have to prove that the tendonitis is a result of what they do on a daily basis.

Otherwise, the insurance company could claim that the employee either had the condition already or suffered it through other activities. If the insurance company decides to decline such a claim, it can be very hard for the employee to prove without medical documentation.

Having workers’ compensation coverage for your employees is the right thing to do both according to the law, and according to respect. They do the work that allows your business to thrive. Make sure that they are safe on the job, but also let them know the parameters for their workers’ compensation claims so that they don’t get denied.

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