Common Workers' Compensation Defenses

One of the main reasons employers and their workers’ comp insurance companies look for ways to deny claim boils down to money. Just as with any other insurance product, your employer pays a high price for premiums to provide workers’ compensation and like other insurance rates, these premiums are affected when injured workers file claims.

The more comp claims that are filed, the higher the premiums will be that your employer has to pay. The premiums are also affected when a particularly expensive claim is filed, so employers and their insurance providers routinely investigate or monitor the daily activities of workers’ compensation claims. For these reasons, you need to seek legal advice when your workers’ comp claim is denied. Having a good defense against a denial will help to get the benefits you deserve.

Often, due to the insurance premium factor, employers don’t feel an injury was serious or even valid. It is commonly believed that an employee who files for benefits due to carpal tunnel or other repetitive stress injuries, or back injuries, are not entirely truthful regarding their injury. Employer bias in these situations can play a large part in your worker comp claim being initially denied.

Injuries that cannot be wholly verified by a medical exam, such as obscure pain generate employer bias the most often. When you claim an injury occurred at work that cannot be confirmed by x-rays or other imaging, your employer or their insurance company will most likely deny the claim initially. Contact a workers’ compensation attorney if you suffer this form of denial so they can help you argue an appeal to this decision.

Employers and their insurance carriers look for any possible reason that will allow them to deny a workers’ comp claim legally. There are situations where an employer will declare your injury did not happen on the workplace, or that you were not working at the time of injury. To qualify for workers’ compensation benefits your injury or illness must be linked to your work activities. This stipulation can mean that if your injury occurred while you were eating lunch, or while you drove to or from work, you are not entitled to compensation.

Another situation of an injury not relating to work activities would be if you do sustain an injury at work but do not report the incident and it worsens while you are away from the job, compensation may not be due. You are responsible for reporting any injuries that occur while performing your job-related duties immediately or as soon as possible. 

When your claim is denied for the reason of injury not being work-related, you will need to gather evidence to dispute this claim. Talk with a workers’ comp attorney and decide on the best course of action to appeal to this decision. You may have to talk to other co-workers and find a witness to the injury who can back up your claim that you were working when the injury occurred. Medical evidence is also helpful as your doctor can show how the injury relates to your job performance. If necessary or if the insurance company requires further proof, you may need to obtain an independent medical exam.

What is an IME? An IME (Independent Medical Exam) can be used to resolve a denial of your workers’ comp claim. There are times when your employer’s insurance company will disagree with a diagnosis from your treating doctor and request an IME to resolve the dispute. This request can be due to the insurance company not agreeing to suggested treatments by your doctor or that the injury is not related to the work you perform. An IME is designed to provide an objective assessment of your medical condition including which treatments and prescriptions will be required to heal you. If you are being asked to obtain an IME, speak with your attorney regarding your options and how this process will benefit your claim.

You have to be employed at the time of filing a workers’ compensation claim. If an injury occurred on the workplace or an illness you've developed is related to the work you were performing, you have to have an active employee status to file a claim for compensation. Your employer’s insurance company can deny your claims if they show you are no longer working at the company where the injury happened.

Contact a workers’ compensation attorney if you have been denied benefits for no longer working where the injury occurred as most states have laws in place for you to contest this form of denial.

You may have reported the injury and then left the job either by choice or a lay-off by your employer. There may be a valid reason for you not filing the claim after you left the company. Another reason could be your employer fired you as a result of your injury (which is not a legal action).

If you're the victim of an injury on the job or develop symptoms of a work-related duty, notify your employer or supervisor immediately or as soon as possible. The deadline for reporting an injury does vary from state to state but the sooner you file the claim, the better the outcome will be for receiving benefits. Typically, you are allowed thirty to ninety days for giving notice, and it is generally acceptable if the notice is given by yourself, your spouse, or your doctor. If the claim is not filed within a specified time, your employer can deny compensation.

You may have reported the injury but failed to file the claim in which case your workers’ comp attorney can argue that notice was given within the required time frame. You may need to talk to coworkers who witnessed you telling your employer, or there may be medical records proving your employer was notified regarding an injury that was reported to have occurred at the workplace.

There may be special restrictions on workers’ compensation claims set in place by your state.  Some examples include long-term emotional stress conditions experienced from work-related duties. There are also guidelines regarding the severity of injuries qualifying for benefits. If the insurance company or your employer determines your injuries are not severe enough to prevent your return to work, they can deny or reduce your claim.

If your claim is denied due to the insurance company disputing the severity of your injury, a medical report should dispute this finding. Talk with your workers’ comp attorney regarding the evidence you will need to ensure benefits are provided to you. It is essential your doctor understands that the reason you are seeking treatment is due to a condition that occurred at your workplace.

Regular physicians are not always able to treat work-related injuries. There are special rules in place regarding the treatment of injured workers as far as receiving payment which is complicated and different from other medical claims. Your physician may choose not to treat your work-related injury and, you will want to receive treatments that can be verified should a denial be received. You are still qualified to receive care, and you will want to ensure it is from a physician that deals with work-related injuries or illnesses.

If an injury is determined to be self-inflicted, your employer is not responsible for providing you with workers’ compensation benefits even if sustained at your workplace. Examples of this would be if you engaged in a conflict with another employee while working and became injured as a result of the fight. If your employer has reason to believe you hurt yourself purposely to receive benefits, they also have grounds to deny your claim.

If your employer or the insurance company accuse you of causing self-inflicted injuries, you may need legal representation to dispute your denied claim. Evidence will need to be gathered through eye eyewitnesses and your doctor to argue your employer’s claim of self-inflicted injury. With the different work industries and the numerous tasks required to complete jobs, employers may misguidedly think you failed to perform your job safely and thus injured yourself intentionally. With the help of a workers’ compensation attorney, you can show you were performing your duties to the best of your ability and injury was not preventable.

Your employer’s insurance company can require that you undergo an IME (independent medical exam) to verify your claim and that it is a work-related injury. These exams are designed to evaluate the extent of your injury and determine what type of treatment you need, how long those treatments should continue, and what if any other medical assistance is required in order to help you heal. Failing to appear at your scheduled appointment for this testing, could give the insurance company grounds to deny your claim.

If you were unable to attend the appointment for personal reasons, you might need the assistance of a workers’ comp attorney to help argue your case. Discuss your options with a workers’ comp attorney to find out how to build a defense against this denial.

If your employer determines your injuries were a result of you performing actions that are illegal or against company policy; they may have grounds to deny your benefits. Examples would include thinking you had been drinking while on the job or engaging in careless behavior that resulted in your being injured. Employers have denied claims for workers’ comp when they feel an employee has not been following safety guidelines outlined in their company regulations.

If you feel your claim has unjustly been denied due to your employer’s belief you were misbehaving on the job, seek legal counsel. A workers’ compensation attorney can help you find the evidence needed to dispute this accusation and assist you in receiving the benefits required to heal from your injuries.

If your employer feels you were ‘horse playing’ on the job, or playing around in any manner that stipulates unsafe work practice when you sustained an injury, they have grounds to deny workers’ compensation benefits. Often behaviors are misinterpreted by different parties, and your employer may have taken your actions as being careless or silly when the accident happened that resulted in an injury. If they, or the insurance company, feel this is the case, your claim can be denied.

If you are being accused of ‘horseplay’ on the job which resulted in an injury, you will need legal representation to argue your behavior. Eyewitnesses will also be helpful in your defense to explain your actions. Speak with a workers’ compensation attorney to help gather the evidence needed to dispute this form of denial.

Workers’ compensation doesn’t cover every worker. Some employees within specific industries are not covered under this insurance like; certain executives, agricultural workers, domestic employees, or employees covered under different policies that are listed as exempt from this form of coverage. Your employer, in these situations, will tell you that you are not covered by workers’ comp and cannot file a claim.

It is true that not all employees are covered under the workers’ compensation program. This fact does not mean your employer is not responsible if you sustain an injury while working for them. If you are injured, and your employer refuses to take responsibility, you need to contact an attorney.

If you receive notice that your workers’ comp claim has been denied, you should not give up. The letter of denial will state the reasons the insurance company feels they do not owe you compensation. If you think the reasoning is a simple misunderstanding, or that it was an error in paperwork, you can contact the claims adjuster and try to clear up the matter. 

If your employer or the insurance company made a mistake and are willing to admit to it, or it was a misrepresentation of specific facts that can be easily rectified, you may be able to have the decision reconsidered. This route is not an easy one and not one that often works in the denial process. When you receive a denial to a workers’ compensation claim, an appeal is often necessary. Contact a workers’ compensation attorney to help you through this as it can be a complicated and stressful procedure. 

The letter of denial you received should provide you with, information needed to file an appeal. The first step for filing a workers’ comp claim in the state of California, is to ask for a hearing in front of your local Workers’ Comp Appeals Board judge. This hearing is an informal process where the judge will listen to both sides and decide whether or not your claim should be accepted. It is to your advantage to have legal representation when going through this hearing.

To request a hearing before the Appeals Board, you (or your attorney) must first file an Application for Adjudication of Claim as a way of officially filing your appeal claim and having a comp case number assigned to it. Following the filing of this application, you must file a form called a Declaration of Readiness to Proceed.

Application for Adjudication of Claim- The form is required in a California Workers’ Compensation case if there is a dispute between an employer’s workers’ compensation insurance company and an injured worker. If the initial claim is denied and the worker wishes to appeal the decision, this form must be filed with the worker’s local Workers’ Compensation Appeals Board jurisdiction. This form will begin the proceedings to appeal any disputed issues involving an injury in the workplace.

DR or DOR (Declaration of Readiness to Proceed)- is implemented in California to declare a workers’ comp claim when a worker injured on the job is ready to move forward with a workers’ comp case. The form is used to request a conference call with their local Workers’ Compensation Appeals Board Office.

This form can be used in numerous ways to resolve issues. Some of the ways it is filed are to resolve compensation rates, medical treatments, vocational rehabilitation, self-procured medical treatments, disability benefits, permanent disability ratings, and other areas the workers’ comp program issues benefits.

Once you submit your Declaration of Readiness to Proceed, you should be scheduled for a pre-trial conference. The notice of this conference will advise you of the time, date, and location of where the conference will be held. During this conference, a workers’ comp judge tries to resolve the issue of whether or not your claim should continue to be denied or accepted.

If the judge feels your case cannot be resolved at this step, they will issue the matter be taken to trial. Sometimes during these proceedings, the judge will determine they need more information to make a decision, or before the issue can be brought to trial. In this situation, the judge will set up a ‘discovery plan’ in order for the evidence needed to be collected. Most workers’ comp cases reaching this stage of the debate are accepted by the insurance company. For those cases that are not allowed, there are other options. Check with your attorney to find out what your next step would be.

The fact is, you should not take a denial notice as your last chance for compensation for injuries or illness you’ve suffered due to performing your duties at work. You should also never feel guilty for initially filing a workers’ comp claim even if your employer feels you do not have a legitimate injury. Seek the help of an attorney if your claim is denied as you have the right to receive medical treatment, take time off from your job to heal and receive compensation for your injuries. Workers’ comp benefits were put in place of your right to sue your employer for these injuries, and it is your right to seek compensation. Your employer or their insurance company will take every possible route to deny your claim, and you need a good legal defense to protect your right to benefits. Contact your workers’ comp attorney as soon as you receive a denial to your claim.

If your claim was not denied to a simple or technical error that is easily cleared, your best option is obtaining the help of a workers’ compensation attorney in filing an appeal. There are a variety of reasons for a claim being denied as has just been outlined, and your best defense is a legal defense.

The appeal process for workers’ compensation claims can be complicated and involve rules of evidence along with civil procedures a judge is going to expect that you understand. One of the main reasons workers lose their workers’ comp appeals is their lack of knowledge with the system. An experienced attorney can prepare a strong case for your defense and help you receive the benefits you need and deserve. 

If anyone you know has had their workers’ comp benefits denied, or if you have been denied a claim in Los Angeles, call Workers Comp Attorney at 310-956-4277. We have the experience and knowledge with California workers’ compensation law and can help you receive the benefits you deserve. Challenging a denial on a workers’ comp claim can become time-consuming and challenging. Allow our attorneys to help you through this difficult time. Let us focus on the legal issues while you focus on healing as we protect your rights.