While there are any number of reasons why an injured worker might have his or her worker’s compensation claim denied, there are some common reasons that come up most often.
However, before I address the most common reasons for denial, it is important for injured workers to find out from their employer, or more likely their case manager representing the insurer, whether their claim is being denied. Often times, injured workers will call demanding a lawyer for their worker’s compensation claim when in fact they don’t even know if they will need legal representation for a denial of their benefits.
Don’t just assume your claim will be denied. It is very common and perfectly lawful for the employer/insurer to conduct an investigation to determine if your alleged work-related injury is compensable. In fact, once an injured worker has given proper notice to his employer of an injury, the employer/insurer has up to 30 days to determine compensability. So…don’t panic, it could be your employer/insurer has not completed its investigation. (Rarely does it take this long for the E/I to make a determination though!)
If it has been more than 30 days, then you need to contact your employer/insurer to find out why you have not received your entitled benefits. Again, I stress in the majority of cases, the claim is accepted almost immediately and the process operates fairly smoothly with the worker receiving proper benefits. But then, there are always exceptions…
This represents a non-exhaustive list of the most common reasons why workers are denied benefits.
Employer Claims Worker was not an Employee
Seems silly right…either you are an employee or you are not, right? Correct, but there are a couple situations to watch out for in which it is not so clear. The primary situation in which this becomes a dispute is in the context of the E/I arguing injured worker is an independent contractor rather than an employee. A full discussion of what constitutes an independent contractor is too long to discuss in this post, but in a nutshell-generally, if you go to work for the same employer every day, receive regular paychecks with payroll deductions such as withheld income tax, and if your work is generally under the control of the employer or supervisor, you will be determined to be an employee.
Occasionally, employers create unique employment structures featuring a variety of forms of compensation, including working for room and board. If you have been injured while employed under non-traditional circumstances, and have questions about your status, you may wish to call and discuss your individual situation with me.
Employer Claims Worker’s Injury was not Caused by Work
Causation—this is a word an injured worker must be familiar with. E/I may admit worker has an injury, but will dispute what CAUSED the injury. Worker will always have the burden to prove a causal connection between the work and the injury, and this is accomplished through a health care provider. If you are not sure whether your injury was caused by your work activities, go ahead and report it, just to be safe.
Employer Claims Worker was not Injured at Work
New Mexico law provides benefits for workers who are injured in the “course and scope of employment”. There can be disputes as to what constitutes course and scope, and this has been much litigated. This tends to be pretty straight forward in most cases, but there can are situations in which worker may be injured driving to work or leaving work, or even injured in the parking lot of work. Maybe even performing work you were not authorized to do. Just be aware that your injury must occur in the course and scope of your employment. If it is not clear, expect your employer to dispute your claim.
Employer Claims it did not Receive Notice
Generally, workers must provide actual or written notice within 15 days of the date of the accident. (There are situations in which the injury does not surface until later so it is critical to file a notice of accident form any time when you are involved in a work accident). What constitutes actual notice can be tricky, but workers are required to provide details surrounding the accident. Simply stating, I got hurt, does not satisfy this notice burden. Any time you are relying on a verbal notice to your employer, you are running a risk that your employer will later claim a lack of notice. Thus, when possible give written notice.
As I stated, there are many other possibilities, but by far most of the disputed claims fall into one of these categories, and each of these categories deserves much more discussion for full understanding.
If you believe you are unlawfully being denied worker’s compensation benefits in New Mexico, please contact me to discuss your claim in greater detail.