Sometimes, employers and TPAs must deny benefits. Here’s why.
Contrary to the opinions of plaintiff attorneys, there are valid reasons workers compensation benefits should be denied. The following are ten common reasons workers comp benefits may be denied, but there are other justifiable reasons to deny workers comp benefits. This discussion is general in nature and will not apply to all jurisdictions, but generally will apply to most states. It’s important to pay legitiamet claims quickly – these claims are considered “compensable.” Claims that are not compensable must be denied by law.
Injury Happens Away From Work
One of the most common types of workers compensation fraud is when an employee alleges an injury happened at work when it actually occurred away from the job. When the employer’s investigation or the claims adjuster’s investigation reflects the injury occurred at a time the employee was not on the job, the workers comp claim should be denied. For an injury to be covered by workers comp, it must occur during the work period and at a location of the employers’ where the employee would be performing the job duties of the employer.
Traveling to/from Work
When the employee works at a fixed location, injuries that occur while the employee is traveling to or from work are not normally covered by workers comp. An injury on the way to work or from work can be covered if the employee is in the process of providing a benefit to the employer. For instance, an errand picking up supplies at the office supply store, when an injury occurs. However, if the employee is traveling to or from work for the employee’s own benefit, the workers comp claim will be denied.
Not Medically Justifiable
When employees reach their maximum medical improvement, they are normally released by the medical provider to return to work, if they have not already returned to work. When the employee does not want to return to work for whatever reason, they may seek to continue their medical treatment. If their treating doctor allows them to remain off work, often an independent medical examination will confirm their continuing to seek medical treatment and to stay off work is not medically justifiable. At this point the adjuster will deny further workers comp benefits.
Late Notice of Injury
Every state requires the injured employee to give notice to the employer in a timely manner from when the employee is aware of the injury or occupational disease. What is timely varies greatly from “immediately” in Washington State and West Virginia to two years in New Hampshire. (Most states have a longer time frame for latent injuries and occupational diseases like asbestosis). If the employee does not report the injury timely, and does not have an excusable reason, the workers comp claim can be denied.
Treated with an Unapproved Medical Provider
In approximately half of the states, the employer selects the medical provider for the treatment of the employee’s injuries. When the employee elects to treat at an unapproved medical provider, the workers comp benefits should be denied.
No Medical Treatment
If an employee calls in to work with an excuse like “I can’t come in to work today, because I hurt my back yesterday on the job,” there are no workers comp benefits when there is no medical treatment. Regardless of how many days the employee claims he stayed home in bed while his back got better, it is not a workers comp claim. There must be medical treatment to verify the nature and extent of the injury, or indemnity benefits will be denied, even when employee remains off work longer than the state’s waiting period.
Insufficient Documentation the Injury is Work-Related
While most non-medically trained people will think injuries like carpal tunnel are always work-related, that is not always the case. Carpal tunnel, hearing loss, and other progressive injuries are often a function of aging or other non-work-related factors… If the medical provider is unable to determine whether the injury occurred as a result of the work done by the employee or is due to non-employment related causes, the worker’s comp claim will normally be denied. When there is insufficient documentation the injury is work-related, the employee will often seek additional medical evaluation until a definite determination of the cause of the injury can be made.
Various jurisdictions will not consider the aggravation of a pre-existing condition as a workers comp claim. For instance, the employee has degenerative disc disease of the lumbar spine. The normal activities of the employee’s job aggravate the degenerative disc disease causing the employee to have back pain. If there is no specific event, which causes pain from the pre-existing degenerative disc disease when a worker’s comp claim is brought, it is denied.
Most states allow the workers comp insurer to deny a claim if the employee is intoxicated at the time of the injury and the intoxication was a contributing factor in the accident that caused the injury. A positive drug test or a positive blood alcohol test is needed for the insurer to deny the workers comp claim. If you suspect your employee is under the influence of drugs or alcohol at the time of the accident, request the emergency clinic or other medical provider to perform a drug test and a blood alcohol test in conjunction with their emergency medical care.
Horseplay, Rough Housing, and Practical Jokes
When the employee is the perpetrator of horseplay, roughhousing or a practical joke and the horseplay, rough housing or practical joke backfires on the employee and the employee gets hurt, in most jurisdictions, there are no workers comp benefits available. Any claim brought by an employee is denied, because the horseplay, roughhousing, or practical joke has no benefit to the employer, and the employee is not considered as being on the job.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com or 860-553-6604.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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