Workers’ Compensation Claims Are Contestable for Many Reasons

When handling workers’ compensation claims, few decisions are as important as whether to accept claims as compensable or contest them.

“A denial may not end the matter,” said Bob Robenalt, an attorney with Fisher Phillips in Columbus, Ohio, and Cleveland. “It often triggers the adjudication or hearing process.”

He added, “One important consideration: while a claim is being adjudicated, the employee may continue to accumulate compensation benefits for time the employee is away from work. Offering light-duty work is one practical way employers can limit those potential compensation benefits.”

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Reasons to Contest a Claim

Employers can contest a workers’ compensation claim for a number of legitimate reasons, Robenalt said, including:

• The employee did not sustain the injury as alleged. For example, if an employee claims they were struck by a forklift but the investigation shows otherwise, the employer can contest the claim.
• The alleged injury did not occur in the course and scope of employment — for instance, if the incident happened before or after the employee’s shift.
• The incident didn’t result in a diagnosable condition or did not require medical treatment.
• The injury resulted from the employee’s own misconduct, intoxication, or drug use, or was in violation of company policy.
• The injured person is an independent contractor and not an employee.

Beth Weeden, an attorney with Perez Morris in Columbus, Ohio, elaborated on reasons for contesting claims, which may include if:

• Surveillance video shows someone tripped over their own feet, and that surface that they were working or walking on was clean, dry, and free from any debris, water, or other work-related hazard.
• The medical evidence contains several different versions of how the employee got injured, and the story about how they got hurt differs each time they seek treatment.
• There is a long history of treatment or problems with the part of the body that was alleged to be injured at work and the employee was actively treating for a specific condition all the way up to the date of the alleged injury.
• No medical evidence establishes a causal relationship between a specific diagnosis and the mechanism of injury that is described.

“A claim can legitimately be contested because someone fails to report an injury for a lengthy period of time,” Weeden said. “However, generally speaking, failing to report an injury alone is not going to be enough to defeat the allowance of a claim.” But if someone is claiming that they had an injury six months ago and they have continued to work their regular, full-duty job without ever mentioning a work injury, it is legitimate to contest the claim, she added.

Toolkit: Understanding Workers’ Compensation

Invalid Grounds for Denial of a Claim

There are several invalid grounds for denying a workers’ compensation claim, Weeden said, including claims cannot be contested because:

• The employer does not like someone or to punish employees.
• The employee was negligent, due to the no-fault nature of the workers’ compensation systems in most states.
• An employer wants to avoid higher workers’ compensation premiums.
• An employer is trying to meet an internal goal of going a certain amount of time without a work injury.
• The injury was caused by a third party, such as a motor vehicle accident in the course and scope of someone’s employment.

“If the injured worker was involved in a work-related motor vehicle accident, they can pursue third-party action against the negligent driver and also file a valid workers’ compensation claim with their employer,” Weeden said. “Under those circumstances, the employer will have a right to subrogation in most states and recover some of the money back that they paid in the workers’ comp claim from the injured employee’s third-party recovery.”

Automatic Denials

“Claim denials are appropriate when the employee’s claim contains errors or other grounds supporting rejection,” Robenalt noted. “That said, automatic denials should be reserved for situations where the employer has a legitimate reason to contest the claim, or where the application itself is erroneous or incomplete.”

In most states, an automatic denial triggers a formal adjudication or hearing process, Robenalt added. “Because that process can take time, it may delay needed medical treatment for the employee — and delayed treatment can lead to worse outcomes. Employers should factor that reality into their decision about whether to contest a claim.”