Five Questionable Workers Compensation Injuries

You are at work. An accident happens. So, you qualify for workers compensation coverage, right? Compensating workplace injuries is why the employer pays for coverage – right? Not so fast, it’s not that easy.

Sometimes, the answer is “sometimes.” There is a big difference between an injury happening at work, and the injury being “work-related.” The golden rule is: the injury has to “occur within the course and scope of employment” and “arose out of the circumstances of employment.” Of course, each jurisdiction states the law slightly differently, so check state law. For more information: Is the injury compensable.

Here are five common examples of questionable compensable “workplace” injuries.

Note: Coverage can vary by jurisdiction. Always check with your adjuster for any scenarios applicable to your particular workers compensation cases.

Back injuries may be the most common of workers compensation claims. An employee, doing normal work duties, feels back pain. Is it covered? Ask these questions:

1. Was the worker doing normal job duties?

2. Was the injury witnessed?

3. Is this an isolated incident?

4. Did the pain start off slowly, then worsen over time or was it more acute in nature?

5. Was it reported promptly and to the proper person?

6. Does the worker have prior back injury claims or prior surgery to the affected area?

The employer may be on the hook for accepting this claim as a strain. However, if later the worker needs surgical intervention to repair ongoing pain, then the claim may be disputed. Reporting the claim late and/or not receiving treatment right away can affect the compensability of the claim. The importance of prompt injury reporting and proper medical treatment can mean the difference between a “back injury” claim being accepted or denied.

Repetitive job injuries are quite common. The same employee comes to work day after day, doing the same job on the same machine for months, maybe years. But whether the job actually caused the injury is the main question. Some states are much more restrictive allowing repetitive injuries than others — so check state law!

If the worker reports a repetitive job injury, and an MRI later shows all kinds of arthritis in the shoulder, then this claim may not be accepted. Unless the worker can prove the job duties led to an aggravation of the pre-existing degenerative conditions, the claim may not be covered. The employer may be on the hook for a temporary strain or exacerbation, but once a surgical repair is recommended, this claim could be denied by an IME physician.

Everyone has a different degree of ongoing arthritic issues in their bodies. There are 25-year-old workers with shoulders looking like they have been through the mill. And there are 65-year-old workers with perfectly healthy shoulders. It all depends on genetics, the job being done, and for how long. The physician must be able to differentiate between what is a pre-existing degenerative arthritic condition, and what damage is specifically related to the job tasks.

Watch out for these claims. Some workers do not run to the doctor for every little ache and pain. Some are afraid to miss work for financial reasons. Some are afraid to report a claim because they are afraid of being laid off or moved to another job classification.

The most important thing for the employer to do in these cases is to document the incident internally. Workers must know it is “okay” to report an incident, but if they don’t go to the clinic for treatment they run the risk of their claim being disputed down the road.

The workers comp motto for claims adjusters is: “Workers injured at work go for medical treatment because they are injured.” The reality is some people do not want to get treatment at the time of the injury. They may have heard the workers comp clinic has bad service; or they have to wait for 3 hours before being seen. These issues are detrimental to the claims adjuster, since a worker may have a legitimate injury but due to these outside factors does not get treatment at once. Failure of the worker to get medical care does not mean the worker is not hurt. It means delays in medical treatment complicate the claim down the road potentially leading to a denial.

Auto accidents in employer vehicles can be tricky. Every state has its own rules when it comes to these types of accidents. Just because a worker is driving a company vehicle does not mean the claim is automatically accepted. A thorough investigation is required. Questions to ask include:

1. What was the worker doing at the time of the accident? Think distracted driving.

2. Where was the worker heading when the accident occurred?

3. What were the worker’s exact job tasks while in the company vehicle?

4. Who was at fault at the time of the injury?

5. Was there a police report?

6. Did the worker get medical treatment at a hospital?

7. Was a drug/alcohol test done at the hospital?

The answers to these and others questions determine if the claim is accepted or not. Sure, if you are on the way to a job site and an accident occurs, you may be entitled to some benefits but there is no guarantee.

Believe it or not, some states actually cover a degree of “horseplay.” The hard part for the adjuster is determining the degree of horsing around that will lead to the claim being accepted or rejected. Typically, it is common practice for the adjuster to deny this type of claim, but not always. Statutes involving horseplay are usually vague, and open to interpretation. The employer needs to do a detailed investigation involving all parties, and the adjuster should take statements as well to see if they match up. After the investigation, consult an attorney to see if the horseplay act causing the injury would be covered.

Just because you suffer an injury at work does not mean you have automatic coverage under the Workers Compensation Act. Every scenario is unique, and most injury details are not the same. The employer plays a very important role in the initial investigation of all claims, and the more details provided to the adjuster, the better decision the adjuster can make as to claim compensability – or not.

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.