Workers’ Compensation requires an employer to compensate an employee for work-related injuries. To receive Workers’ Compensation, an employee usually has to file a claim and wait for the insurer to investigate it. If the insurer finds that the employee’s claim is valid, the employee will receive financial compensation for his or her injury.
This isn’t always the case, though. Sometimes, an employer or insurer will deny the employee’s claim on the grounds that he or she is ineligible for Workers’ Compensation. Here are some common defenses employers and insurers will use in order to deny workers’ compensation claims.
Employee Failed to Give Notice of Injury
- When an employee is injured on the job, Workers’ Compensation laws require him or her to give notice of injury to the employer within a certain amount of time. The deadline varies from state to state, but usually ranges from 30 to 90 days. Notice may be given by a third party, such as the employee’s spouse or doctor, and may be given verbally or in writing, to a supervisor. However, if notice of injury is not given within the specified length of time, the employee’s claim is invalid.
Statute of Limitations Expired
- Each state also has a deadline for filing a Workers’ Compensation claim. This is known as a statute of limitations, and usually ranges from one to three years. For claims involving occupational disease—rather than accidental injury—the statute is generally more flexible. In most cases, though, if you fail to file a claim before the statute of limitations runs out, you will probably be ineligible for Workers’ Compensation.
Injury was Self-Inflicted
- Workers’ Compensation generally does not apply to self-inflicted injuries. This includes injuries an employee sustains in a fight that he or she started, and injuries inflicted intentionally to receive Workers’ Compensation.
Injury Not Related to Employment
- To qualify for Workers’ Compensation, an injury must be linked to activities relevant to employment. This means that an injury sustained during an employee’s lunch break, or during the commute to or from work, generally do not qualify. Additionally, an employee who sustains a minor injury on the job, but fails to properly care for it, or engages in activities outside of work that worsen the injury, will probably not qualify for Workers’ Compensation.
Employee Failed to Attend Doctor’s Appointments
- To qualify for Workers’ Compensation, the claimant must undergo an independent medical exam. This helps verify their claim and determine the extent of the injury. However, if they fail or refuse to this exam or fail to attend follow-up appointments, their claim may be reduced or denied.
Injury is not as Severe as Employee Claims
- If an employee’s claim that a work-related injury prevents him or her from returning to work is found to be false based on the available evidence, then the employee’s claim may be reduced.
An Employee is Injured while Committing a Crime, or While Violating Company Policy
- If an employee sustains an injury while intoxicated at work, or while engaging in careless behavior that violates the company’s policy, he or she may not be eligible for workers’ compensation. Employers often use the defense that an employee was acting carelessly at the time of an injury, thus claiming that a Workers’ Compensation claim is void.
Cause of Injury Unknown
- In order for a Workers’ Compensation claim to be successful, the cause of injury must be determined by an independent medical practitioner. If the cause is unknown, the insurer cannot determine whether or not the injury was work-related, and the claim cannot be processed.
Workers’ Compensation Statistics
According to the Injury Impact Report released by The Travelers Companies, based on data from over 1.5 million workers’ compensation claims filed from 2010 to 2014:
- The most common work-related injuries are strains and sprains, which make up 30% of on-the-job injuries. Next are cuts or punctures, which make up 19%. Contusions follow at 12%, and inflammation and fractures each make up 5% of work-related injuries.
- In small businesses, cuts or punctures are the most frequent types of work-related injuries. In manufacturing and construction, eye injuries are most frequent.
- Strains and sprains result in an average of 57 days off of work, while cuts and punctures result in an average of 24 days off of work.
- Inflammation and fractures generally cause the most days off of work, with inflammation causing an average of 91 days and fractures an average of 78 days.
- Handling of materials is the most common cause of work-related injury, followed by slips, trips and falls, colliding with or being struck by an object, accidents with tools, and traumas that occur over a period of time (through prolonged strain on a certain part of the body, for example).
Should You Hire an Attorney to Help You with Filing Your Claim?
You can file your own Workers’ Compensation claim; an attorney is not required. However, serious injuries, or claims arising from the actions of third parties, or complex situations involving later-developing injuries or illnesses can all affect which statutes of limitation apply to your case. If you miss an applicable legal deadline, you may permanently lose part or all of your potential Workers’ Compensation.
Having a Workers’ Compensation attorney as your advocate during the claim filing process is a good insurance policy against the possibility of you inadvertently missing a statute of limitation-based cutoff date or inadvertently disqualifying yourself for Workers’ Compensation.