Previously, I wrote an article addressing what happens when a workers’ compensation claim is denied. Often I am asked why an individual’s workers’ comp claim has been denied. In workers’ comp legal land, the reasons for workers’ compensation denials are generally called “defenses”. The most common workers’ comp defenses are:
- Intoxication
- Willful acts
- Willful disobedience of statutory duty or safety violations
- Failure to file the claim within two (2) years
- Intervening event
Intoxication: Basically, if you are drunk or on drugs at the time of the injury or death, then you are not entitled to benefits. This is why often following a work-related injury, the employer requires the injured worker to take a drug test. Although drinking and drugs may mean that you are not entitled to workers’ compensation benefits, under certain circumstances, this defense may not be allowed by the Industrial Commission, so it is best that you contact a workers’ compensation attorney for a consultation even if you think that your case may be denied because you had drugs or alcohol in your system at the time of your injury.
Willful Acts: If the employee’s intention was to die or injure him- or herself, that employee is not entitled to workers’ compensation benefits. It does not matter whether the employee’s intent was to inflict serious injury. However, it should be noted, that if the suicide is a natural consequence of a compensable injury or disease, then the suicide will not be considered “willful” under the statute and will be held to be compensable under workers’ compensation benefits.
Willful disobedience of a statutory obligation or safety regulation: These rules are NOT made to be broken. Technically, this is a not a basis for a denial. However, if a worker fails to adhere to safety rules or statutory obligations, it may cause an injured workers’ benefits to be reduced by as much as 10%. It must be shown that the employee was told of the statutory obligation or regulation prior to the injury.
Failure to file the claim within 2 years: See my recent post regarding the reporting requirements and the statutes of limitation for workers’ compensation claims. If your claim is not filed within those applicable time frames, your claim may be denied.
Intervening Event: Typically intervening events really falls into the vein of pre-existing conditions. This usually means that there is a question of causation with these cases and often the employer/insurance company is arguing that the injury was pre-existing and thus not caused by the workers perceived injury.
While there may be a number of reasons that a workers’ compensation claim has been denied, most reasons tend to fall into one of the above categories. Although the workers’ compensation adjuster may tell you your claim has been denied based on one of the reasons above, I would recommend that you consult with a workers’ compensation attorney to discuss the facts of your case to determine whether you may have any further recourse regarding your denied claim.
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