Top Reasons Workers Comp Claims Are Denied in Florida

When you suffer an injury at work in Florida, you may assume your workers’ compensation claim will be approved without issue. Unfortunately, this is not always the case. Workers’ compensation insurance companies sometimes deny valid claims, leaving injured workers struggling to cover medical expenses and lost wages. Understanding why claims are denied and what steps to take if it happens to you is essential for protecting your rights.

If you had your workers comp claim denied in Florida, our Miami workers’ compensation lawyers can help you appeal the decision. Contact us today for a free case review.

Why Was My Florida Workers Comp Claim Denied?

There are several major reasons why workers’ compensation claims are denied in Florida.

Missing the Time Limit to Report a Work Injury

One of the most common reasons workers’ compensation claims are denied in Florida is because the injured worker did not report the injury within the required time frame. Florida law requires that workplace injuries be reported to an employer within 30 days of the accident. Failing to do so can result in a claim being denied.

If you delay in reporting your injury, the insurance company may argue that your injury didn’t occur at work or that it was less severe than claimed. Immediate reporting creates a clear link between your injury and your employment.

The Injury Is Not Work-Related

For a workers’ compensation claim to be valid, the injury must have occurred during the course of your employment. If the insurance company believes that your injury happened outside of work or during an activity unrelated to your job duties, they may deny your claim.

For example, if you were hurt while engaging in horseplay or while commuting to or from work, your claim could be denied. In some cases, the connection between your work and the injury may not be straightforward, making it critical to provide clear evidence that your injury was job-related.

Pre-Existing Injury

Having a pre-existing injury can complicate your workers’ compensation claim. Insurance companies may argue that your current injury is simply an aggravation of an old injury and not a new work-related injury. They may deny the claim or attempt to reduce your benefits, stating that your condition existed before the work accident.

While Florida workers’ compensation law allows for compensation when a work injury exacerbates a pre-existing condition, providing thorough medical documentation is crucial to show how the work-related incident worsened your condition.

The Injury Was Caused by Intoxication

Your workers’ comp claim can be denied if you were under the influence of alcohol or drugs at the time of the accident.

Florida workers’ compensation laws include a presumption that an injury was caused by intoxication if a drug or alcohol test administered after the work accident comes back positive. To overcome this, you would need to provide evidence proving that your impairment did not contribute to the accident.

Lack of Evidence or Witnesses

Another reason workers’ compensation claims are denied is due to a lack of sufficient evidence or witness testimony. If your injury occurred when no one else was around or if there are conflicting accounts of what happened, the insurance company may claim that there isn’t enough proof that the injury happened at work or is as severe as you claim.

Documentation is critical to avoid this issue. Ensure that you have detailed medical records, photographs of the injury or accident site, and any witness statements from coworkers who saw the incident.

Not Seeking Medical Care Right Away

If you don’t seek medical treatment right after the injury, the insurance company may argue that your injury isn’t as serious as you claim or that it didn’t happen at work. Florida workers’ compensation law requires that injured workers obtain medical treatment from a healthcare provider approved by the employer or insurance company.

Delays in seeking treatment can raise red flags with the insurance company and lead to a denial of your claim. Be sure to seek immediate medical attention after a workplace injury and follow all prescribed treatments.

What to Do If Your Workers’ Compensation Claim Is Denied

If your workers’ compensation claim is denied, it’s important not to panic. You still have options to pursue the benefits you deserve. Here’s what you should do:

Contact Florida’s Employee Assistance and Ombudsman Office

Florida’s Employee Assistance and Ombudsman Office (EAO) provides free services to help injured workers navigate the workers’ compensation system. If you’re confused about the denial of your claim or unsure of the next steps, the EAO can provide guidance on resolving disputes with the insurance company.

The EAO may also assist you with obtaining the necessary documentation or filing an appeal. While they cannot provide legal advice, they can be a helpful resource if you are struggling to understand the reason for the denial.

File an Appeal with Help from a Lawyer

If your claim is denied, you have the right to appeal the decision. Filing an appeal can be a complex and time-sensitive process, and working with an experienced workers’ compensation attorney can significantly improve your chances of success.

A workers’ compensation lawyer can help you gather additional evidence to support your claim, such as medical records, witness testimony, or expert opinions. They can also represent you during the appeals process, ensuring that your case is presented effectively.

The Workers’ Compensation Appeals Process in Florida

If your workers’ compensation claim is denied, you can file a petition for benefits with the Florida Division of Administrative Hearings (DOAH). This begins the formal appeals process, which includes several key steps:

Filing a Petition for Benefits

After your claim is denied, you have two years from the date of the injury or one year from the date of your last workers’ compensation payment to file a petition for benefits. This petition must be filed with the DOAH and should include detailed information about your injury, your employment, and the reason for the claim.

Your lawyer will prepare and file this petition on your behalf, ensuring that all required documentation is submitted to support your claim.

Mediation

Once a petition for benefits is filed, the next step in the appeals process is mediation. Mediation is an opportunity for you, your employer, and the insurance company to negotiate a settlement with the help of a neutral third party.

Many workers’ compensation disputes are resolved through mediation, as it allows both parties to avoid the time and expense of a formal hearing. During mediation, your lawyer will work to negotiate a fair settlement that covers your medical expenses, lost wages, and any other benefits you’re entitled to.

Formal Hearing

If mediation fails to resolve the dispute, the case will proceed to a formal hearing before a judge of compensation claims. This hearing is similar to a trial, where both sides present evidence and call witnesses.

Your lawyer will present your case and argue that your injury is compensable under Florida workers’ compensation law. After hearing the evidence, the judge will issue a decision on whether you are entitled to benefits and, if so, how much.

Appeals to Higher Courts

If the judge rules against you in the formal hearing, you have the option to appeal the decision to the First District Court of Appeal in Florida. This step is usually reserved for cases involving complex legal issues, as it can be a lengthy and expensive process.

Working with an attorney throughout the appeals process is essential to ensure that your case is handled properly and that all deadlines are met.

Contact Our Miami Workers’ Comp Attorneys Today

Workers’ compensation claims in Florida can be denied for various reasons, from missing the deadline to report an injury to disputes over whether the injury was work-related. If your workers comp claim is denied, don’t lose hope. There are steps you can take to appeal the decision and pursue the benefits you deserve.

At Workers’ Compensation Lawyers Coalition in Miami, our experienced attorneys are here to help you navigate the complexities of the workers’ compensation system. Whether your claim has been denied or you’re just beginning the process, we can assist you. Call (786) 686-2857 today for a free consultation and learn more about how we can help.