Can An Employee Be Denied Workers’ Compensation? – Everything You Should Know!

Under the Workmen’s Compensation Act 1923, workers who are injured due to a workplace accident receive coverage through the WC policy. 

It includes medical expense coverage, loss of wages, and rehabilitation coverage, which helps workers receive treatment and maintain their financial stability. 

However, there are certain circumstances and reasons for which a labour insurance policy claim of an employee can be denied. Awareness of these reasons can help employees avoid such circumstances and receive their compensation rightfully. 

In this article, we will examine the workers’ compensation denial reasons, enabling claimants to remain prepared during times of need.

What Are The Workers’ Compensation Denial Reasons?

Multiple reasons lead to workers’ compensation denial. Let’s understand it part by part.

1. Non-Work Related Injuries

A WC policy claim from an employee can be rejected if the injuries sustained by them are non-work-related or outside the scope of their employment. 

For example, if an employee gets into an accident while commuting to the office, it will not be covered under the policy unless the vehicle used is employer-provided. 

2. Injury Due To Employee Negligence

Employees cannot make any claim under the labour insurance policy in case their negligence or misconduct was the reason for their workplace injury. It includes working while under the influence of alcohol or drugs, or not following the safety protocols clearly stated by the employer. 

3. Not Seeking Medical Treatment

Failing to seek immediate medical attention after the injury is another reason for denial of a WC policy. Not receiving medical treatment raises suspicion about the severity of injuries. 

Thus, employees must receive immediate medical treatment, follow the after-injury care instructions, and consult a doctor as required to provide medical proof of their injuries. 

4. Pre-Existing Conditions

Suppose the employee has any pre-existing illness or condition before joining the current organisation, and the workplace injury is determined to be unrelated to their current job. 

In that case, the labour insurance policy claim will be rejected. Moreover, it is always advised to disclose your pre-existing condition to your employer.

5. Intentional Injuries

Any form of self-harm or self-inflicted injuries will not be covered under the WC policy. In some cases, the employee may even face punitive actions for their conduct. 

6. No Timely Reporting Is One Of The Primary Workers’ Compensation Denials Reasons 

Delays in the timely reporting of injuries are another reason for the denial of workers’ compensation policy claims. 

Employees should inform their employers immediately after an injury so that the employer can notify the insurer. 

Some insurance companies have a specific timeframe for reporting workplace injuries. Failure to timely report not only raises suspicion but can also lead to claim rejection.

7. Workers’ Compensation Denial Reasons: Lack Of Medical Proof

A labour insurance policy provides coverage to employees for workplace injuries and occupational illnesses. 

However, to receive compensation on medical grounds, employees must prove they have suffered an injury or illness. Thus, it is crucial to have sufficient medical evidence pointing out that injuries or illnesses sustained by employees are really work-related.

8. Incomplete Documentation Is A Workers’ Compensation Denial Reason

Claiming the WC policy is all about proper documentation and completing the necessary forms. If an employee fails to provide all the required documentation, then their claim will be rejected. 

Thus, it is crucial to keep a record of every document, such as medical reports, claim forms, medical bills, doctor’s certificates, disability certificates, death certificates, and FIRs (if required). 

9. Employer Denies Claim

There may be circumstances when the employer disputes the claim to reduce their financial liability. 

They can argue that the employee was not working at the time of the injury or claim negligence on the part of the employer. 

If the employer can prove their claim, for example, through CCTV footage or other documents, then the WC policy claim can be rejected. 

10. Dissimilarities In Injury Report

Another reason for rejecting a labour insurance policy claim is a discrepancy in the injury report. Frequent cases of information change raise suspicion. 

It indicates that the employee is attempting to commit fraud against the employer and insurer to obtain compensation, which may result in the claim being rejected. 

How To Avoid The Workers’ Compensation Denial Reasons?

Here are some ways employees can avoid WC policy claim rejection. 

• Be proactive about reporting the injuries immediately to the employer so that the claim can be initiated within the time frame. 
• Maintain complete and accurate records of all documents. It includes your medical reports, claim form, hospital bills, etc. 
• Communicate clearly with the employer and insurer, accurately inform them about the accident, and provide your support wherever required. By doing so, you can avoid any misunderstandings. 
• Seek legal advice from a lawyer if your case involves several complexities or if you find it hard to understand the legal procedure of a WC policy claim. 
• Appeal for denied claim, do not lose hope, understand the reason behind the claim rejection, and reapply. 

Workers’ Compensation Denial Reasons And How A Reliable Insurance Company Can Help

Rejection of WC policy claims can happen due to various reasons. Incomplete documentation results in rejection. 

Employees often indulge in negligence. These include delays in jury reporting, not seeking medical attention, and so much more. However,  employees often feel their claim is rejected in a discriminatory manner. Therefore, they can always seek legal help. 

But the course of action is to avoid such a situation and follow every rule for the claim procedure. 

The best way to avoid any such trouble is to choose a reliable insurer, such as TATA AIG. 

Therefore, TATA AIG is clear in its communication and has a straightforward claim procedure to minimise rejections or conflicts.

A reliable insurance company takes the stress off your shoulders.  People generally seek assistance to reduce their burden during times of medical crisis. Therefore, the victims of accidents find it difficult to overcome the challenges during the hours of need.

Families of the injured often struggle to cope with rejected claims. The injured person also finds it challenging to participate in lawsuits and other legal proceedings.  Therefore, this increases the financial burden on the victims.

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