When Can My Employer Deny Workers’ Compensation?

Workers’ compensation provides a system in which a person who is injured on the job can receive compensation for such injuries without having to sue his or her employer. However, not all claims are approved, leaving the worker injured and uncompensated.

Workers’ Compensation Process

When a person suffers a job while performing job-related tasks, he or she typically files a claim. The employer then conducts an investigation before it agrees to pay out benefits. Not every claim is valid or compensable. An employer who believes that the claim is not valid or compensable may deny the claim. There are a number of defenses that an employer may raise.

Not Covered by Insurance

Workers’ compensation does not necessarily cover every worker. Independent contractors are commonly exempted from coverage. Certain executives, domestic employees, agricultural workers or individuals covered under different policies may also be exempted from coverage. While this may not mean that the employer is not legally responsible for injuries, it may be adequate grounds to deny the workers’ compensation claim.

Failure to Provide Notice

Injured workers must provide notice to their employer when they suffer a work-related injury or develop an illness related to work. State laws establish a deadline by which the employee must provide notice, such as 30 days, 45 days or 90 days after being injured or learning of the illness. Some states require notice in as little as four days. If the employee does not report the illness within this period of time, the employer may be able to deny the claim. Additionally, state law may specify the type of notification that must be provided, such as a written statement.

Statute of Limitations

Additionally, an employer may be able to deny a workers’ compensation claim because the relevant statute of limitations has passed. This statute of limitations determines the time limit in which the injured employee must bring forth a claim. Once the time elapses, the employee can no longer pursue the claim. There may be exceptions to the general statute, such as if the employee suffers from an occupational disease.

Not Caused by Work

Workers’ compensation coverage only provides benefits for injuries or illnesses related to employment. An employer may allege that the employee’s injury was not caused by work. The cause of the injury has to be determined before the claim can be paid. An injury may have occurred at work but be attributed to different reasons, such as a heart attack. An independent medical examination can help determine the cause of the injury.

Intentional Actions

Workers’ compensation is generally only available for accidents. It may cover the negligent actions of coworkers but not their intentional actions. For example, a claim may be based on a coworker not following safety instructions but not for assaulting his coworker. Additionally, workers’ compensation is not available for the claimant’s self-inflicted injuries, including work injuries that he or she intentionally caused in order to file a fraudulent claim.

Willful Negligence

The claimant’s own willful negligence may be another reason why the claim is denied. For example, if he or she gets intoxicated or violates safety rules, the employer may use these actions as a defense to the claim. Horseplay may also exclude the claimant from being able to recover.

Not Seeking Medical Treatment

In order to receive benefits from workers’ compensation insurance, the claimant must usually seek medical treatment. Additionally, the employer may require the employee to receive an independent medical examination from a doctor of its choosing if state law provides for this process. Failing to attend such medical appointments may be grounds to deny the claim.

Injury Is Not Compensable

Some injuries may not be compensable, based on state law. For example, stress-related injuries may be difficult to prove and may not be compensable.

Injury Is Not as Severe as Reported

If an injury does not prevent the claimant from performing his or her regular job duties as originally reported, he or she may have to return to work sooner. This will cause his or her benefits to be reduced.

Filing an Appeal

An injured worker may wish to file an appeal if his or her workers’ compensation claim is denied. A workers’ compensation attorney may be able to appeal a denial.

Provided by HG.org

Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.
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