Common Workers Compensation Defenses

Just like all workers’ compensation cases, a workers’ compensation claim case is to be defended by the accused who is the employer and/or the workers’ compensation insurance provider. Therefore, these parties are allowed to prepare a defense against the employee. The defenses are meant to eliminate the employer’s fault to some extent. The stronger the defense, the weaker the employee’s case will be and the chance to receive his/her workers’ compensation benefits.

Here are some of the common defenses that your employer or a compensation insurance provider will use against you to deny you or reduce your workers’ compensation benefits that are rightfully yours.

Employees who injure themselves intentionally are not compensated. While this sounds odd, there have been cases in Long Beach of employees who inflict injuries on themselves so as to receive compensation benefits in an attempt to defraud the company. If the employer successfully argues that you are lying to the company about the injuries to get benefits and time off work, your compensation claim will be rejected.

For example, if Tim was sitting on an office chair that he didn’t know was broken and he fell down straining his back, he is entitled to compensation benefits since his action was not intentional. But if Tim knew the chair was broken, but he sat on it anyway knowing it could result to an injury so that the company pays him while he takes some days off, the employer could use this evidence to deny Tim his workers’ compensation claim.

However, this defense only works if the employer proves that you inflicted the injury on yourself and you did that deliberately so as to receive benefits. A claim that the employee intentionally caused his/her own injury is not admissible in court.

In California, workers’ compensation laws dictate that injured employees should provide notice of the injury/illness to their employer within 30 to days from the date the injury happened. This is applicable whether you have developed the injury/illness over a period of time or it was a sudden occurrence due to an accident at the workplace. The notice should either be in written or verbal form and it should be given to the direct supervisor of the job. It can be given by the employees’ children, doctor, spouse, fellow employees, or any other person.

You should submit your compensation claim form to the employee within the stipulated period of time. Your employer then sends this form to the workers’ compensation insurance provider who commences the process of releasing your benefits. If you don’t give notice to your employer, he/she may use this in court and your benefits could be denied, reduced, or delayed.

A statute of limitations refers to the time limit for an employee to file a workers’ compensation claim. This is different from the time limit of providing a notice of injury. In California, the statute of limitations is one year from the time the work-related illness/injury occurred. This means that injured employees have up to one year to file their workers’ compensation claim. However, the statute of limitations is flexible in cases where an employee suffers a disease or an injury caused by long-term exposure to toxic substances at work. In this case, you are allowed to file a compensation claim within a year after the last known exposure.

If you fail to file your compensation claim within a year since you became aware of the injury or the disease, your chances to recover compensation for the injuries will be limited, or there might be no chance at all.

Notice of potential eligibility is a written document that accompanies the claim form provided by the employer. The notice normally has the following information:

• An account of the various types of workers’ compensation benefits

• The procedure that will be used to start proceedings for the acquiring of the workers’ compensation benefits.

• From whom or where the injured employee can obtain medical treatment

• What happens to the claims form after the employee has filed it

• The rights of the injured employee to change his/her doctor

• How the employee will get treated while the claim hasn’t gone through yet

• How the employee will be protected from discrimination as provided by the law

• The function of the primary treating doctor that the employee is provided with

You have a right to contest this notice if you are not contented with it. You should do this within 30 days of receiving the notice. If you do not contest the notice then later dispute it at the hearing, it will prevent you from pursuing the claim. Your employer can also have the upper hand since they may use this to argue the claim be dismissed or the benefits reduced for failure to dispute a notice of potential eligibility in a timely manner.

If you contest a notice of eligibility, your employer might be willing to settle the matter through negotiations. After negotiations, if you are still not satisfied, you have a right to file for adjudication to bring the case before a workers’ compensation judge. The adjudication is filed with the Workers’ Compensation Appeals Board. This application must be filed within a year of the date of the injury, the date the medical care ended, or the last date on which the employer paid the temporary benefits. You also have to file a ‘Declaration of Readiness’ document with the Workers’ Compensation Appeals Board to show that you are prepared to proceed with the hearing. Filing this application late may be used by your employer to argue that your benefits are null and void.

Filing for a hearing may be delayed if the employee had a legal excuse of not doing so. Even then, he/she must provide proof before a judge.

If you claim that you need some time off because an injury you sustained while at work prevents you from performing your job duties, but your employer provides evidence that indicates otherwise, your compensation benefits may be reduced and you may be required to return to work sooner.

Normally, in each company, there are safety rules that an employee must adhere to. If you violate any of these rules or carry out your duties while under intoxication resulting in an injury, the injury will not be covered under workers’ compensation. Thus, during a workers’ compensation lawsuit, an employer may claim that you injured yourself because you were not following the rules and proper protocol of the company. This is a common defense for employers as many will use this defense even if it is not true.

However, if the employer proves his/her claims, you may not receive your compensation benefits. There are cases where the employer and the employee tend to disagree on who was negligent at the time of the injury. Additionally, an employer can argue horseplay as a workers’ compensation defense if he/she can prove that the injuries are as a result of your carelessness. These defenses may equally have your compensation claim rejected.

Here is a scenario of horseplay/willful negligence: while in her office, Mary accidentally drops a water glass on the floor and breaks the glass. Instead of getting rid of the glass particles immediately, she leaves it on the floor. As she continues with her work, she forgets that there is broken glass on the floor. As she stands to leave the office, the broken glass cuts her leg causing an injury. In this case, Mary would not be compensated for the injury as she neglected her duty which led to the injury.

For you to claim a work-related injury, its cause must be linked to the activities of your employment. This means that any injury you sustain on your way to or from work may not qualify. An employer may argue that you were not at work nor were you engaging in any of the company’s activities when you got injured. This applies even if you sustained a minor injury at work but did not seek medical care for it, which worsened the condition, or other activities you engaged in outside the limitations of your work made the injury to escalate. For example:

1. Terry accidentally steps on broken glass while at work and sustains a minor wound which she doesn’t tend to. After some time, the wound gets infected and worsens to a point where it needs proper medical care or she risks being amputated. Terry is not eligible for the company’s compensation benefits;

2. Fiona, a hotel worker, slightly cuts her finger while chopping vegetables, sustaining a minor injury that could heal. But then, she goes home and in the process of preparing food, she injures herself again at the same spot and worsens the wound. Fiona will not be covered under the company’s workers’ compensation program since her activity was not within her employment limitations.

Note that a work-related injury can happen anywhere including at home for those employees who telecommute. In addition, business trips and parties are within the limitations of employment which makes them applicable.

An employee must have proof that the injury cause is linked to employment; otherwise, he/she risks being denied compensation benefits. Generally, this defense revolves around the arguments that the activity that led to the injury is not related to the employee’s work and the employee was not on duty during the occurrence of the accident.

A part of your workers’ compensation claim involves a medical examination. This is necessary to help verify your claim and define the amount of benefits you will receive. The basis of this defense is that an injured person cannot decline medical treatment. Therefore, an employer can argue that your workers’ compensation benefits be denied or reduced since you missed a medical appointment. Missing a doctor’s appointment may suggest that your injury is not as serious as you imply.

Failure to attend a doctor’s appointment, MRI, x-ray, or physical therapy sessions is a strong defense to deny you benefits or reduce the amount. An insurance provider also has a right to file hearing seeking to suspend your compensation benefits until you comply with medical appointment schedules.

An employer may claim that the injury was caused by employee conditions that already existed before he/she was employed. He/she may use this defense to avoid paying for a degenerative condition or any injury you previously sustained that is not related to your current employment. If your pre-existing condition is not associated with your injury or benefits claim, the employer has no right to use this defense. For instance, all along, Brad has had a dislocated ankle due to a car accident that happened earlier. One day as he is walking, he accidentally slips and falls on an unmarked wet floor causing a major disability that requires urgent medical care. The employer cannot use this as a defense to deny Brad his benefits since his condition did not have any impact on the new injury.

If the pre-existing condition caused an injury that was a non-workers compensation, the employer is only liable to pay for the aggravation. It is possible that the employer will try to challenge the claim depending on the extent to which the condition was worsened. Additionally, if you have a pre-existing condition that you are already receiving benefits for, then worsen that condition by sustaining a work-related injury, your employer should pay for the worsening of the condition. In these situations, however, the employer will likely seek to reduce your benefits citing the pre-existing condition.

You qualify for workers’ compensation just like any other employee who did not have a prior injury because your injuries are new as well. Yet, insurance companies and employers are fond of using this defense to deny employees their benefits since they do not want to lose their businesses by incurring a lot of payments. They partner to try and prove that the injury is not related to the employee’s work, but it is due to a pre-existing condition.

For an insurance provider to process your workers’ compensation claim, the cause of the injury must be established. This is because some injuries may occur at work but they are not work-related, for example, during a seizure. Here, the employee has to explain what caused the accident. Injuries or illnesses with unknown causes are not covered under a workers’ compensation claim unless it was worsened by a work condition. Say, for example, if you cannot explain what caused your back sprain, your employer will use this absence of knowledge as a defense to deny your claim. The cause of the injury can be established through an independent medical examination.

If the job application required you to indicate any previous health conditions, but you did not do so even if you actually had one, you are not eligible for a workers’ compensation benefits. For instance, you indicated on the application form that you had no prior spinal problems but you previously had a spine injury. Even though this does not prevent you from having a valid claim to your benefits, your employer might use this defense to try and reduce your benefits.

In Long Beach, independent contractors are not entitled to a workers’ compensation claim. Many employers often claim that their employees do not need workers’ compensation coverage because they are independent contractors. However, this defense rarely holds ground because the employer will have a hard time proving your status as an independent contractor. On several occasions, the administrative law judge presiding over workers’ compensation hearing will determine that the injured employee was a worker at that company when the injury occurred.

This is based on an argument that if it is possible for the employee to be hired or fired by the company, or if the tools and equipment used by the employee are provided by the company, or if the company manages all the details and conditions of the work, and if the employee is a regular worker at the company, then the worker is more of an employee than an independent contractor. The employee also has an advantage as there is no factor that determines whether a worker is an independent contractor or an employee.

It is common in Long Beach for employees to try to falsely claim workers’ compensation benefits. If an employer is able to prove that you committed fraud in order to receive compensation benefits, your claim will be blocked. In California, it is unlawful for an employee to:

• Deliberately making a false material statement or representation in order to get workers’ benefits

• Deliberately present a false verbal or written material supporting or denying a compensation claim in order to obtain or refuse workers’ compensation

Some of the workers’ compensation fraud cases include faking an injury, filing numerous workers’ compensation claims, partnering with a physician to inflate the cost of injury treatment, physicians billing for the care they never provided with the help of the employee, and doctors reporting a disabling injury to continue treating the employee.

Since insurance companies find many injuries difficult to prove or diagnose, they often use this defense to deny employees their benefits. For instance, it is not easy to prove a soft tissue, neck, back or head injury. They, therefore, falsely accuse the employee of committing fraud with an allegation that he/she is faking an injury. They fail to understand that just because they cannot get evidence of the injury, it doesn’t imply that the employee was fraudulent.

There are cases where a doctor would advise an employee to do some exercises to help them recover quickly. An insurance cover may use this against the employee to claim the employee was not really injured. For instance, if the insurance company was stalking you and took pictures of you jogging or swimming, they will present this as evidence to claim that you are faking the injury. An employee can fight this by providing medical reports showing a doctor’s medical recommendation to carry out such exercises.

Additionally, insurance company investigators can go as far as trailing your social media platform or that of your close friends to identify any possible signs of fraud they can use against you. For instance, say you recently suffered an injury, even though you are supposed to be on bed rest, you invited some friends over just to kill the boredom. In the process, you took some pictures of you being active. One of your friends posted the pictures in which you looked active on social media. If the insurance company or your employer sees these pictures, they might use them to prove that your injury is not real.

While these defenses are only supposed to be used if the employer has substantive evidence, we have cases in Long Beach, CA, where some employers are fabricating evidence to deny or reduce their employees their share of the compensation benefits. Don’t let this happen to you. Contact Workers’ Compensation Attorney at 714-716-5933 and let us help you. Our attorneys specialize in workers’ compensation law and they will advise you accordingly from the moment you file your compensation claim to the time you receive your benefits.