Every employer is required to have workers’ compensation insurance to ensure that employees receive financial support for the time away from work as well as medical treatment necessary to recover in the event that they get injured on the job. California’s Workers’ Compensation Act was created to take workplace injury cases out of the courtroom. It’s also designed to make it easier for employees to get benefits following a work-related injury or illness, while at the same time limiting the amount that the employees would have to pay.
Unfortunately, insurance companies and employers don’t always comply with California’s workers’ compensation laws and they might seek to avoid paying out claims when possible. Insurance companies are known to notoriously develop tactics to deny or devalue a worker’s claim. Just like any other type of case, workers’ compensation cases are usually defended by the accused. In other words, when an employee suffers a workplace injury and they seek compensation from their employer, the law allows the employer (and the employer’s insurance provider) to defend themselves against the injured workers’ claims.
In essence, these defenses are used to diminish the employer’s fault to a varying extent. It is more like a dimmer switch. The stronger the employer’s common defense is, the dimmer the employee’s case would shine. We cover a number of the common, well-established defenses that your employer or their insurance company might use against you to avoid paying workers’ compensation benefits that you are entitled to.
Employee Failed to Give Notice to the Employer
Under California Workers’ Compensation laws, injured workers are required to provide their employers with notice of job-related injuries within 30 days of becoming aware of the condition. This applies whether you’ve developed a work-related illness or injury over a period of time or you’ve been injured in a sudden workplace accident. The notice should be given to a supervisor or manager in writing or verbally, and may also be given by your doctor, spouse, or other third-parties.
A DWC-1 claim form must be submitted to the employer within 30 days, and the employer will then send it to the worker’s compensation insurance provider. Failure to give notice to your employer could reduce or hold up your benefits, and for that reason, your employer may use this as a defense against you in a lawsuit to recover workers’ comp.
Not Filed Within Statute of Limitations
The statute of limitations, in this context, is the time limit for filing a workers’ compensation claim. In California, injured employees have up to one year from the date of the work-related injury or illness to file a claim. The statute of limitations is separate from the deadline for providing notice of the injury and is also more flexible in cases of occupational disease such as those caused by exposure to chemicals and toxins. In such a case, you may be allowed to file a claim within one year after the last known exposure. Failure to file your workers’ compensation claim within one year of becoming aware of your illness or injury will void your ability to recover for the injuries.
Injury Was Self-Inflicted or Intentional
While most injured workers in Orange County have valid workers’ compensation claims, there are some who intentionally injure themselves so as to receive workers’ comp benefits. This defense is meant to avoid payouts to workers trying to defraud the system. Under the “self-inflicted” injury defense, the employer argues that the employee is trying to cheat the workers’ compensation system by causing his or her injuries in order to get some time off of work and get compensation.
This defense has nothing to do with claiming that the employee accidentally caused his or her own injury. For this defense to be applicable, the employer must show that the worker caused their own injury and purposefully did so to get benefits. There’s a clear difference. Workers’ compensation is meant to cover misfortunes caused by an accident or the employee’s carelessness.
For instance, say Andrew accidentally dropped a mallet on his foot in the course of his work. In this case, it’s obvious that Andrew dropped the mallet accidentally, and was not trying to get workers’ comp benefits. However, since his employer has workers’ comp coverage, he may be entitled to recover benefits. But say Andrew intentionally dropped the mallet on his foot so he could take a few days off of work to watch midday world cup games while still getting benefits. The employer could rightfully use this defense against Andrew’s workers’ compensation claim.
Injury Not Causally Linked to Employment
For an employee to be eligible for workers’ compensation benefits, the injury or illness must be linked to activities that are within course and scope of his or her employment. This means that an injury sustained during an employee’s commute to or from work or during the lunch break generally do not qualify. Employers use this defense by arguing that the employee was not technically at work or engaging in a work function when they got injured, and the employer is therefore not liable for the injury. This defense also applies in cases where a worker sustains a minor injury on the job but engages in activities outside the scope of their work that worsen the injury or he/she fails to take seek medical care of properly take care for it.
A work-related injury can happen at any location and can even happen at home since many people are now telecommuting. When employees are on a business trip, they are well within the course and scope of employment the entire time. However, there must be proof to show that the injury is linked to activities relevant to employment.
For example, if a waitress gets tripped over by a customer’s dog while taking the customer’s order, that would likely be a valid claim because she was in the course and scope of employment. And no matter who was at fault, the employer cannot use the “no causal link to employment” defense against the waitress’ claim. But if the waitress was knocked over by as she was walking home after work, she was obviously not on the clock and not performing her employment duties. The employer’s defense would hold up in this case.
Put simply, this defense typically rests on two factors, either the worker wasn’t clocked in at the time of an accident, or the activity the worker was engaged in was not related to his/her work.
Willful Negligence or Horseplay
When applicable, an employer can argue that against an employee’s worker’s compensation lawsuit on the basis that the worker injured him/herself while goofing off or being careless. The main issue with this defense is that many employees apply it even in situations when the injured worker did no such thing.
If the employee was displaying reckless behavior or was engaged in misconduct that violates the company’s policy at the time of the injury, he or she may not be entitled to workers’ compensation. This also involves performing one’s job duties while intoxicated. An employer can argue that horseplay led to the injury, thus claiming that the employee's claim is void.
For example, Jane and George share the same office and have become friends. They make jokes and generally enjoy each other’s company. One afternoon, George arm wrestled Jane, dislocating her shoulder. This is considered to be horseplay because it has nothing to do with their job functions and the idea of wrestling is risky and dangerous, with the potential to cause major injuries. Horseplay is a defense that can get blurry in some cases and can work to the employer’s advantage.
Employee Did Not Attend Doctor Appointments
Part of a workers’ compensation claim involves an independent medical examination, which is typically required to verify a claim and also determine the amount of benefits that an employee is entitled to. In addition, an injured employee cannot unjustifiably refuse medical treatment. Therefore, the employer can argue that the employee should not receive workers’ comp benefits if they miss a medical appointment, either a doctor’s appointment, a scheduled x-ray or MRI, or a physical therapy visit. The insurance provider can also file a hearing to suspend benefits until the worker cures the refusal of medical treatment.
Failure to show up to your appointment can result in reduction or denial of your claim. As an injured employee, you have the responsibility of seeking medical treatment, complying with your treating doctor’s recommendations, and attending functional capacity evaluation (FCE) or an independent medical evaluation (IME) if it is scheduled by the insurance carrier.
Unable to Determine or Explain Cause of Injury
In a workers’ compensation case, the employee bears the burden of proof and must, therefore, show why the accident happened. Idiopathic injuries are typically not covered by workers’ comp unless a specific risk of employment has worsened. For instance, if you do not know what caused your slip and fall accident, your employer may use your lack of knowledge as a defense and will likely deny your case. Even injuries or illnesses that occur at work such as seizure, or heart attack can be as a result of factors that are not related to employment.
Injury Not as Bad as the Employee Claims
If a worker asserts that a work-related injury prevented them from performing their regular job duties or from returning to work, but evidence suggests that the claim is false and they may be required to return to work sooner, then the employee’s workers’ comp benefits may be reduced.
Injury Was Caused by a Pre-Existing Condition
An employer may assert that the injury was caused by an employee’s pre-existing condition in order to avoid paying for a degenerative condition or pre-existing injuries that are not related to the employee’s work. Under California Workers’ Compensation law, an employee is entitled to receive benefits if the injury is covered. If your pre-existing condition is not related to your injury or worker’s compensation claim, then your employer must allow the case to proceed as normal. For instance, a worker has a pre-existing back problem and one day slips on an unmarked spill, causing a greater disability that required new or change of medical care. In this case, the pre-existing condition had no influence whatsoever on the new injury and the employer cannot use this as a defense to refuse an employee’s claim.
But if the pre-existing condition resulted from an injury that was a non-workers comp, your employer is only responsible for the aggravation. However, chances are that the employer will challenge your claim regarding the extent to which the pre-existing condition has been impacted. For instance, say you twisted your wrist in an accident at home but have been wearing a brace at work as recommended by your doctor. You slip on a hidden slip and your wrist is fully sprained. Your employer will be liable for the aggravation of your injuries but your benefits may be reduced.
In addition, if you have a pre-existing condition related to a worker’s comp claim, and then re-aggravate or further injure that same condition, your employer is required to pay for the worsening of your condition. However, your employer will likely seek a reduction of the benefits because of the pre-existing condition.
Your injuries are new and this means you qualify for the same benefits as other employees who did not have any prior injuries. Insurance companies are notorious for using this defense to deny workers compensation benefits. Insurers don’t want to lose business and employers want to keep their premiums low. So they work together to try to prove that the injury is not work-related and is as a result of the pre-existing condition.
Contact an Orange County Workers Compensation Attorney
These defenses are only meant to be used in the purest sense and only if the accusation against the worker is factual. Unfortunately, employers and their insurance providers will employ these defenses to deny your workers’ compensation claim, leaving you lacking seemingly automatic coverage. That’s why you need an attorney by your side to get your side of the story, review your case, and take on your employer if necessary. At Orange County Workers Compensation Attorney, we’ve been standing for the rights of injured employees in Orange County and throughout California for years. We’ve helped many injured employees get the benefits and workers’ compensation benefits they’re entitled to under the law. So, no matter what defense is raised by your employer or the insurance carrier, we can help. Give our work injury attorney a call at 949-423-3212 or fill our online consultation form for a complimentary case evaluation.