8 Common Defenses to Workers' Compensation Claims

The workers’ compensation system protects employees who get hurt on the job. An injured employee typically files a claim after suffering a work-related injury. Then, the insurer investigates the claim before paying out benefits. The two main categories are occupational disease claims and accidental injury claims.

Insurance companies, like the ones hired by your employer or the self-insured employers, support injured workers by paying for medical bills and lost wages. But sometimes the insurance carrier or third-party administrator managing the claim challenge your injury. They may even hire a workers’ compensation defense lawyer to argue against your claim.

If you find yourself in this type of situation, it’s in your best interest to have your own workers’ comp attorney on your side.

Workers’ Compensation Doesn’t Cover All Workers and Injuries

Not all workers and on-the-job injuries are compensable. Employers and insurers have several workers’ compensation defenses that may apply to a given claim.

For example, imagine an independent contractor falling and severely spraining their ankle when they slipped on an unmarked, freshly mopped section of the floor. While the company may have been found negligent for not marking the slippery floor, the worker is not an employee. So, they are not eligible for workers’ compensation benefits.

Depending on your circumstances, your employer and their insurance provider may deny your claim using any of the eight following workers’ compensation defenses.

1. Failure To Give Notice to Your Employer

State workers’ compensation laws require you to notify your employer of the workplace injury within a specific time. It varies by state, but this deadline is typically 30 to 90 days from the injury.

For instance, Illinois workers must notify their employers within 45 days of the incident. Notice should be given to a supervisor either verbally or in writing. Notice may be given by the employee’s spouse, doctor, or other third parties.

When you get hurt at work, you should first tell your boss or supervisor. If you don’t, it can lead to issues with your claim later. Insurance companies may deny your claim for failing to follow your state’s Workers’ Compensation Act requirements.

2. Missing the Statute of Limitations

Each state has a time limit for filing a workers’ compensation claim. This is separate from the deadline for providing notice of the injury. Time limits typically range from one to three years. These statutes of limitations are usually more flexible in cases of occupational disease, such as injuries caused by prolonged exposure to toxins.

For example, you may be required to file the claim within a set period after the last known exposure. Failure to file your claim within the statute of limitations will void your ability to recover for injuries.

The statute of limitations determines how long you can wait before you start a legal process. For workers’ compensation cases, you must act quickly. If you wait too long, a defense attorney could argue that you lost your chance to claim workers’ comp.

3. Self-Inflicted Injuries

Insurance companies do not cover injuries you cause to yourself on purpose. Injuries caused by the claimant are not compensable. This may include injuries the claimant sustained intentionally to file a fraudulent claim.

Another example would be injuries from a fight that the claimant started. If a workers’ compensation defense lawyer can prove your injury was self-inflicted, they can stop your claim.

4. No Causal Link to Employment

To claim a work-related injury, there must be some causal link to employment. An ordinary workers’ compensation defense is to claim that the employee’s injury is not related to employment activities.

For example, a factory worker gets a minor scrape on their finger but fails to care for the wound properly. The finger becomes infected and eventually has to be amputated. They probably would not be eligible for coverage.

Workers’ comp is for injuries that happen because of your job. If your injury did not happen because of your work, insurance companies might not pay. A defense attorney might argue that there is no causal link to employment. This means that they argue that your job did not cause the injury.

5. Not Attending Doctor Appointments

Part of your claims process involves an independent medical examination. The exam is used to verify your claim and determine the amount of benefits required. Failure to attend your appointment may be either grounds for denial of your claim or result in a reduction in the amount.

You are expected to see a doctor and follow their advice when you are hurt. If you miss appointments or ignore the doctor’s instructions, the insurance company may think you are not as hurt as you claim to be.

6. Injury Not as Serious as Claimed

Insurance carriers may use your medical records to argue that your injury is not as bad as you say. If you claim an injury prevents you from performing your regular job duties, but evidence suggests otherwise, you may be required to return to work sooner, and your benefits may be reduced. They might refuse to pay for medical benefits or argue for lower compensation.

7. Willful Negligence or Horseplay

If a workers’ compensation defense attorney can prove that your injury resulted from willful negligence (like not following safety rules) or horseplay (fooling around on the job), your claim might be rejected. The workers’ compensation system does not cover these actions. If you violate your employer’s safety rules or perform employment duties while intoxicated, for example, workers’ compensation will not cover any resulting injuries.

In many cases, the employer and employee may have differing accounts of which party was negligent. Employers may claim horseplay as a workers’ compensation defense if the claimant’s injuries result from wasting time or being careless.

8. Unable To Determine Cause of Injury

Sometimes, it isn’t clear what caused an injury. The cause of the injury must be determined to process a workers’ compensation claim. Even injuries that occur at work, such as heart attacks, can be caused by factors not related to employment.

The cause of the injury is determined through an independent medical examination. The insurance company might not have to pay if a defense lawyer can successfully argue that it is unclear how your injury happened.

An Attorney Can Help You File or Appeal Your Workers’ Comp Claim

Determining whether you have a valid workers’ compensation claim isn’t always straightforward. Some complex situations may require legal help. An attorney can evaluate your claim and help spot any possible workers’ comp defenses your employer may use to invalidate your claim. Being proactive can help you secure the maximum benefits you’re eligible for under the law.

Your attorney can strategically position your case and help you understand what to expect next. They can also help with mediation meetings with your employer’s insurance company.

Because state law is relevant, your legal advisor should also be licensed in the state where you work. FindLaw’s directory of workers’ compensation attorneys can get you started. Select your state or city to review contact and ratings information for local experts. Many law offices offer free consultations.