X

WHY ARE SOME WORKERS’ COMPENSATION CLAIMS DENIED?

Personal Injury Attorney Brian McDonnellPut into place in 1915, the Pennsylvania Workers’ Compensation system provides employees with medical treatment and compensation for lost wages associated with work-related injuries and disease. For employers, the system provides immunity from direct lawsuits by employees. Under Pennsylvania law, workers’ compensation coverage is mandatory for most employers.  Those who do not have the mandatory coverage may be subject to lawsuits by employees and to criminal prosecution by the Commonwealth.

Employers and their insurance carriers may have a financial incentive to deny claims. Hourigan, Kluger and Quinn workers’ compensation attorney Brian McDonnell notes that “some of the denials such as those for missed deadlines may seem indisputable. In other instances, however, the claim may simply be denied in hopes that you will not contest the denial and file a claim petition.”

Some reasons for denying claims include, but certainly aren’t limited to, the following:

Employee waited too long to report injury

In order to receive workers’ compensation benefits, you must report your injury or illness to your employer in a timely manner. The Pennsylvania Workers' Compensation Act requires that notice of an injury be given within 120 days of the injury.

In some circumstances, such as occupational diseases and cumulative trauma injuries, the time for giving notice does not begin until the employee knows, or by the exercise of reasonable diligence should know, of the existence of the injury and its possible relationship to employment. This exception to the notice requirement is known as the “discovery rule”.

Employee waited too long to file claim

The Workers Compensation Act states that “In all cases of personal injury all claims for compensation shall be forever barred, unless, within three years after the injury, the parties shall have agreed upon the compensation payable under this article; or unless within three years after the injury, one of the parties shall have filed a petition as provided in the Act.” The discovery rule may extend the three-year time period.

Injury didn’t occur at work or while employee was “on the clock”

An injury is compensable under the Pennsylvania Workers' Compensation Law only if it occurs within “the course and scope of employment”. If the injury occurs while an employee is furthering an employer’s business, and if the injury meets all other requirements of the Act, it will be compensable regardless of whether it occurred on or off the employer’s premises.

Commuting to and from work is generally not in the course of employment. There are, however, exceptions to the “come and go rule”. Those exceptions include:

  • The employee has no fixed place of work;
  • The employee is on special assignment for the employer; or
  • The employment contract included transportation to and from work.

Injury was the result of “horseplay” 

If you were injured because you were engaging in horseplay while on the job, the employer or insurance company may try to deny your claim. However, the Commonwealth Court of Pennsylvania made it clear that the bar for such a denial is extremely high.

In Camino v. Workers' Compensation Appeal Board, 796 A.2d 412 (Pa. Cmwlth. 2002), the Court stated that “in order to be ineligible for benefits, the employee must not only have been injured while in violation of an order, but must have been engaged at the time of injury in an activity so disconnected with his or her regular duties as to be considered, with respect to the employer, nothing more than a ‘stranger' or ‘trespasser’.”

Lack of witnesses or video

An injury with no witnesses or video footage is more likely to raise suspicion, as there is no one to back up your claim. In circumstances such as this it is especially important to report the injury to your supervisor immediately while details are still fresh in your mind. It is crucial to remember and document all of the details so your account of the incident remains consistent over time.

Pre-existing condition

Workers’ compensation insurance carriers often deny claims based on the injured worker’s pre-existing conditions or prior work injuries. It is important to remember that you may receive workers’ compensation benefits if your work injury aggravates, accelerates, or exacerbates that previous work-related condition.

A pre-existing condition need not be related to your employment. For instance, harm from a car accident can be worsened by conditions at your current workplace. Only the new injury that is the basis for the claim must be related to work. What’s more, in Pennsylvania workers’ compensation cases involving pre-existing injuries, the employer is required to provide compensation for the entire injury, not just the aggravation of the existing injury.

Failure to provide information / lack of cooperation

While insurance companies have the right to review any medical records related to your work injury claim, they cannot require you to sign medical releases or provide a recorded statement. Still, insurance companies often portray a refusal to sign a release or provide a statement as lack of cooperation. This tactic does not typically produce a valid reason for denying a claim.

It is prudent to not discuss a case with the insurance company prior to consulting an experienced workers’ compensation attorney.

Alcohol / illegal drugs

Intoxication or illegal drug use may bar an employee from collecting workers’ compensation benefits. Under Pennsylvania law, if an injury would not have occurred but for an employee’s intoxication or illegal drug use, that employee is not eligible for workers’ compensation. On the other hand, if an injury would have happened whether or not the employee was impaired, intoxication or illegal drug use may not be relevant with regard to workers’ compensation. However, the employee may be disqualified under the “course of employment” provision.

In these types of cases, the employer has the burden of proof to show that the worker was actually intoxicated at the time of the incident, and that the intoxication was a key cause of the accident.

Injured worker was not an employee

Workers’ compensation is designed to compensate one category of workers – employees. So this type of denial seems straightforward.

However, it is not uncommon for employers to misclassify employees as independent contractors. Between 10-20% of employers misclassify at least one employee as an independent contractor. With workers so classified, businesses are generally not responsible for workers compensation premiums or payroll tax obligations. If you feel that you were wrongly classified, you need to have your status verified before you can proceed with a workers’ compensation claim.

Employee was injured by a third party

Pennsylvania’s Workers’ Compensation Act may cover injuries resulting from an assault by a co-worker. However, that the assault must have been for reasons related to that employee’s employment.

In Kohler v. McCrory Stores, 532 Pa. 130 (Pa. 1992), the Pennsylvania Supreme Court explains that the Workers’ Compensation Act excludes from its coverage attacks upon an employee “so long as the reasons for the attack are purely personal to the assailant. In such a case, the plaintiff is permitted to pursue his common-law remedy.” That remedy would consist of an intentional tort lawsuit against the co-worker. The plaintiff may also be able to make a legal claim against the employer based upon negligence in maintaining a safe workplace.

An experienced workers’ compensation attorney can be invaluable in guiding an injured employee through the challenging claim process.

If your claim has been denied, call (800) 760-1529 to speak with a Hourigan, Kluger and Quinn’s workers’ compensation attorney.

jelly pixel