Workers’ Comp Laws In Nevada: Why Claims Get Rejected

According to the State Bar of Nevada, workers’ compensation, a no-fault insurance plan, provides guaranteed financial payments for work related injuries and illnesses. Financial compensation includes lost wages (i.e. temporary disability payments), medical bills, and lump sum permanent disability payments. The vast majority of claims get accepted, but some studies show that approximately 13% of all claims are initially denied. These findings vary case by case, and depend on the state in which the claimant resides. What we know for sure is that claims do get denied, and sometimes it’s easily preventable.

The Claim Wasn’t Filed In a Timely Manner

There is a statute of limitations on filing a worker’s compensation claim. In some states, Texas for example, one has only 30 days to file a claim. In Nevada, if a claimant doesn’t file a C-4 form within 90 days of the injury they are almost certain to be denied.

Contributory Actions

If someone is involved in a work-related accident, but has been found to have fault in that accident, that is grounds for denial. If insurance companies can show that the claimants’ own actions caused or contributed to their injuries they are then absolved from accepting those claims.
Not Enough Evidence That the Accident Was Workplace Related
If there is inadequate evidence that an injury (or illness) was caused or worsened by the workplace, or if they cant link the injury to the job, insurance companies can reject a claim outright. Claimants must present proof that they suffered injuries while in the course of their regular duties. This is also extended to remote and delivery workers. They are covered under the state’s worker’s compensation program as well, and they too must provide proof that the injury or illness occurred “during the course and scope of their employment”.

Drug and Alcohol Related Injuries

Claims for injuries sustained at the workplace while inebriated or under the influence of a controlled substance have a very strong chance of being denied. This falls under the contributory guidelines. Moreover, depending on the company and the employees role, this may even be illegal. At the very least, if a claimant’s role requires certain certifications, permits, or licenses, they can be revoked indefinitely or for a specified period of time.

The Claimant Fails to Provide Medical Records

Failure to provide necessary medical records related to the workplace injury may lead to a worker’s compensation claim being denied. The insurance company is going to want to review the medical records to assess the injury, determine its work-relatedness, and take note of potentially pre-existing conditions, as outlined in NRS 616C.177.

Discontinuation of Medical Care

If a claimant ceases to seek medical care for any injuries sustained at the workplace, this is also grounds for denial. This may lead the insurance company to believe that the injury has reached “maximum improvement”, that the claimant is not complying with doctor’s orders, or that the injury never happened in the workplace at all. All of which would absolve the insurance company from having to accept and pay out the claim.

Right to Appeal:

If a claim is denied, the employee has the right to appeal any claim rejection they think is based on invalid grounds to the Hearing Office. Similarly, insurance companies typically have the right to appeal a decision requiring them to pay a workers’ compensation claim. The insurance company’s dispute usually involves a claim’s validity or the amount of benefits owed. In any case, a skilled attorney can help effectively appeal any claim decision provided the proper conditions are met.

By Daryl K. Jones

Press Contact: LaGuardia Media and Public Relations