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Why Are Some Worker’s Compensation Claims Denied?

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Archive: May 2015

Why Are Some Worker’s Compensation Claims Denied?

Occasionally, worker’s comp benefits can be denied. Although worker’s comp claims do not require the claimant to prove fault, they do require extensive documentation of employment and medical injury. There are some cases in which the denial is legitimate, and some cases where it is not.

Denied worker’s comp claims can, however, be appealed with the help of experienced California workers’ compensation attorneys. Lawyers can investigate if the reason for denying your claim is legitimate and assist you in the appeals process to get the compensation you need. If you filed a worker’s comp claim and it was denied, it may have been for one or more of the following common reasons:

The Injury Did Not Happen at Work

The most common reason for denying worker’s comp benefits occurs when it is found that the injury did not actually occur at work. This usually indicates the employee is intentionally dishonest by claiming that the injury happened at work when it in fact happened outside of the work schedule and not at the job location.

The Injury Happened When Traveling to or From Work

Unfortunately, injuries sustained while commuting to or from work are not usually legitimate for worker’s compensation. However, there are exceptions to this rule. If the employee was providing their employer with a benefit, such as delivering a parcel or running office errands, the claim is legitimate. If, however, the employee was simply traveling to work, the claim can be denied.

No Medical Justification

Similar to a personal injury lawsuit, a worker’s comp lawsuit requires the claimant to document all medical treatment for it to be covered. Once an employee’s condition improves, he or she is considered healed and able to return to work. If the employee decides not to return to work, he or she does have the right to seek additional medical treatment, but will need to undergo a third party medical exam. If the exam finds the worker is in full health and able to work, any further worker’s comp benefits will be denied.

Statute of Limitations

Every state has different limitations on filing worker’s comp claims. The state of California requires that any worker’s comp claims must be filed within 1-5 years, though your employer must be notified of the injury within 30 days.

If a reported injury sustained from 2 years ago leads to new medical problems, you are eligible for benefits. However, if you never filed a report with your employer, your benefits will be denied. There are some exceptions to this clause, like if the injury resulted in an inability to file a claim, like a coma, or injuries that require long-term treatment or are contagious and require quarantine. No matter when the injury happens, it is imperative to report it to your employer and doctor as soon as possible and keep adequate documentation.

No Documented Medical Treatment or Insufficient Documentation of Work-Related Injury

If an employee is injured on the job and does not receive medical treatment, they have no eligibility for benefits. It doesn’t matter if the employee missed three weeks of work because of the injury. If there is no documented medical treatment, there will be no compensation.

Similarly, if the medical treatment is documented, but there is no documented relation between the injury and the workplace, the claim may be denied. For example, if an employee receives treatment for tendonitis or carpal tunnel, and the doctor does not expressly state he or she believes the injury was caused by work, the claim may be denied. However, the employee does have the right to seek further medical opinions.

If you have filed a claim for worker’s comp and your claim was denied, you may be able to appeal the decision. Contact our competent California workers’ compensation attorneys today for a free consultation.

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Are Temporary Employees Covered By Workers’ Compensation?

Worker’s compensation claims are often complex and stressful by nature. If you’ve been injured on the job, not only do you have to deal with the injury itself. Medical expenses, claimant forms, and possible loss of work must be managed for a period of time. This alone can be confusing, but if you are injured as a temporary employee, the situation can be even more convoluted. The type of employees eligible for worker’s comp varies widely from state to state. Luckily, most temp workers in the state of California are considered employees, with only a handful of exceptions.

The Definition of Employee Can Vary

When filing a worker’s comp claim, you must first ensure you are covered. Not all states require that businesses buy worker’s comp coverage, and even those that do require coverage can be vague in their definitions of what an employee is.

For example, independent contractors, like freelance workers, are not eligible for worker’s compensation benefits. However, it is not uncommon for companies to classify workers as independent contractors when they should actually be considered legitimate employees.

Traditionally, volunteers are not considered employees, though some industries will opt into coverage, such as fire departments who hire volunteer firefighters. In addition to these types of employees, there are several other workers who are exempt from worker’s compensation, including:

  • Agricultural workers. In many states, agricultural workers and farmers are not eligible for worker’s compensation.
  • Domestic workers. Housekeepers, babysitters, and other domestic workers may not be covered.
  • Temp agency workers. Usually, temp workers are eligible for worker’s comp through the agency or the company they were “leased to” at the time of the injury.
  • Seasonal workers. Employees who only work during certain times of the year may not be eligible for worker’s comp in all states.
  • Undocumented workers. In California, undocumented workers are ineligible for worker’s comp.

The state of California requires that all employers secure worker’s compensation coverage in some way or another. This means it is possible that non-traditional workers, like the ones listed previously, are eligible for worker’s compensation. However, the process to receive compensation may be a bit more in depth.

Instead of being able to easily prove you are an employee of a company, the case may need to be investigated further. For example, in the case of a temporary worker, the relationship of the employee in regards to the two employers may need to be examined to determine liability. In this type of case, there are many factors that go into a liability decision, including whether the employer has expressed control over the employee, whether the employer had the right to fire the employee, and who had the employee on payroll. Though it may seem that the “borrowing” employer should be the one to pay out the worker’s comp, this is not necessarily the case.

Usually, the state of California considers both to be employers: the temp agency is the “general employer,” and the borrowing employer is the “special employer.” In most cases, the financial aspects of the worker’s comp are assumed by the temp agency, though there are exceptions to the rule.

Contact an Experienced Attorney to Determine if You’re Eligible

If you have been injured at work, even if you are a temporary worker or independent contractor, you may still be eligible for worker’s compensation. In this situation, it is imperative to contact competent California work injury attorneys experienced in compensation claims. Lawyers are well-versed in the complicated worker’s comp laws and will be able to tell you if your claim is eligible. Likewise, if you have been told by your employer that you are not eligible for worker’s comp, you should contact an attorney because that may not be correct.

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Is Too Much Stress or Developing a Mental Health Issue Covered By Workers’ Compensation?

When first hearing the term worker’s comp, most people picture a physical injury like a back strain or chemical burn in association with the claim. However, it is possible that some people receive worker’s comp benefits because of a mental issue arising from the workplace. If you are considering filing a worker’s comp claim for a psychiatric issue, it is important to contact a California workers’ compensation attorney for legal advice. Worker’s comp claims can be complex to handle on your own, and claims of a psychiatric nature are notoriously hard to win without professional counsel.

Like all worker’s comp cases, documentation of an actual injury will need to be provided for the claim to be legitimate. When a worker is injured on the job, he or she needs to fill out a claim form and submit it along with a physician’s report. This process is no different for claims of a psychiatric nature. Though worker’s comp claims do not require anyone to be at fault to receive benefits, they do require thorough documentation. Mental health worker’s comp claims will need even more extensive documentation in addition to background investigations. This is why it is beneficial to hire competent counsel. An experienced attorney can tell you if your claim is eligible for compensation.

Examples of Mental Worker’s Comp Claims

Mental health complications from a job are hard to prove. The nature of mental health problems in general can be transient and hard to pin down, which is why mental health worker’s comp claims are often dismissed unless a competent attorney is assisting in the claim.

However, there are some claims more commonly seen in worker’s comp cases. For example, if you witnessed an injury or death of a coworker, and in turn suffered from mental trauma like PTSD, you are eligible for worker’s comp. If you suffer an injury which results in a state of depression or debilitating anxiety, you may be entitled to compensation. If you work in a notoriously stressful job, you may be able to get compensation if you are not properly trained and a mental health problem develops because of your work situation. To prove a mental health claim, there are several questions that will need to be answered. These include:

  • What is the nature of the mental health issue? Is it permanent?
  • Is the stress or mental health issue directly related to work? Can it be proved?
  • Was the stress which caused the mental health injury above the normal amount of stress for the job?
  • Was there a pre-existing mental health condition that was exacerbated due to work stress?

How Mental Health Worker’s Comp Claims Are Investigated

All people have some sort of stress level involved in their jobs, but occasionally, stress can become so bad it causes emotional breakdowns, physical complications, and even permanent impairment. In the state of California, employees can file worker’s comp claims for mental health issues, but only with extensive documentation. The employee must prove the workplace was more than 50% at fault for the stress related issues. To prove this, the physician’s report will be examined along with medical history, prior financial, personal, or family issues.

The state will also examine the employee’s work background, including work progress, satisfaction, coworker statements, and performance reviews. As you can see, filing a worker’s comp claim for mental health issues in CA can be an arduous process. If you have sustained a mental health injury or illness resulting from an incident at work, it’s important that you contact experienced California workers’ compensation attorneys to help you navigate through the extensive documentation and get you the compensation you need.

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What Job Sectors and Income Groups Are Most Likely to Use Workers’ Compensation Benefits?

Worker’s comp benefits are designed to protect employed workers from losing income when they are injured on the job. Usually, compensation claims pay for incurred and ongoing medical expenses and are a percentage of lost wages due to injury sustained while on the job. When an employee is injured on the job, it is his or her responsibility to file a worker’s comp claim and get a documented physician’s report to substantiate the assertion.

Worker’s comp claims are not based on fault, and therefore claimants are eligible to receive benefits whether or not they had held partial responsibility in the injury. Personal injury suits are usually only implicated when there has been an act of gross negligence or if a third party is involved. Benefits can be given as temporary wage replacement or permanently if the employees have sustained injuries that will alter their abilities to work for the rest of their lives.

While almost all businesses are required to have some form of worker’s comp coverage, not all workers are entitled to benefits if they are injured on the job. Some industry workers are more susceptible to job-related injuries than others. In these cases, worker’s comp benefits are generally higher as the risk of injury is higher.

Common Industries for Worker’s Comp Claims

Workers comp claims cost the United States billions of dollars each year, which is why the CDC and agencies like OSHA take every step possible to ensure workplace safety.

Warehouse and Industrial Work

Some of the most common trades to seek worker’s comp claims are warehouse and freight transportation industries. People who work in these sectors are often exposed to detrimental respiratory conditions like asbestos or dank working environments. However, the most common warehouse injury results from using the forklift improperly, or if the forklift is not maintained correctly. According to OSHA, there are roughly 34,900 serious forklift injuries every year, 84 of which are fatal. Most forklift injuries occur during loading and unloading, and around 42% of forklift injuries are a result of the forklift tipping over.

Construction Workers

Another common job for injuries is in the construction industry. There are roughly 6.5 million construction workers in the United States, and fatality rates for this industry are higher than the national average of any other industry. Though less serious injuries occur quite frequently, like sprains, breaks, and repetitive motion injuries, the occurrence of fatal injuries in the construction industry is high because there are more ways to be seriously injured. The most common serious or fatal injuries are usually due to falls from heights, scaffolding collapses, and electric shocks.

Industries That Work With Chemicals

Employees in certain industries can expose themselves to hundreds of chemicals on any given day and therefore chemical injuries in the workplace are quite common. Chemicals absorbed through the skin can cause significant illnesses and even death. Though it is hard to measure the exact amount of incidents per year, OSHA estimates that nearly 860,000 illnesses from occupational chemical exposure happen annually. While there are many occupations in which employees expose themselves to chemicals regularly, some of the biggest industries for injuries are nurses and hospital workers, manufacturing plants, mining, cleaning industries, and even office workers. The most common chemical injuries are rashes/burns, respiratory injuries, and brain injuries from inhalation.

Although recent studies have not indicated any particular income range that is more likely to file worker’s comp claims, the nature of blue collar jobs does suggest that people who work in these income brackets and industries are more likely to be injured on the job. If you have been injured on the job and are filing a worker’s comp claim, it’s important to contact a California workers’ compensation attorney as soon as possible. Experienced attorneys can help you navigate through the complex process involved in a claim and get you the amount of compensation you deserve.

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What is Workers’ Compensation Discrimination

After a workplace injury or illness, you have the right to file for workers’ compensation benefits without retaliation or harassment from your employer. Employers in California are required by law to provide employees with access to workers’ compensation coverage. When they discriminate against you for taking advantage of your right to compensation, they are committing a crime.

Most of the time, workers’ compensation will be filed simply and easily with the full cooperation of an employer. Some employers looking to minimize their losses after an accident, however, may try to take action to keep an employee from maintaining gainful employment. Rumors of unethical practices may prevent some employees from filing for workers’ compensation in the first place. You should never be afraid of filing for workers’ compensation to help you recover from a job-related illness or injury.

Common Forms of Discrimination

Workers’ compensation discrimination can take many forms, from subtly removing responsibilities from the injured employee to finding a reason to prevent the employee from coming back to work at all. Here are some common forms of discrimination cited in lawsuits against employers:

  • Demoting or reducing wages as a result of filing a claim.
  • Failing to consider workers’ compensation employees for promotion.
  • Firing or otherwise terminating an employee after a workers’ compensation claim has been filed.
  • Rejecting or otherwise interfering with the process of applying for workers’ compensation benefits.
  • Using threat or force to discourage an employee from filing a workers’ compensation claim.

Any other act that can be linked to a workers’ compensation claim may be considered employee discrimination. If the way your employer treats you starts to change as soon as you file for workers’ compensation, you should consider consulting an attorney to learn more about your rights as an employee and the options you have for taking action against unethical behavior.

Your workers’ compensation attorney will fully investigate your case. Many cases arise from unfair termination after employees return to the job. The history of your company, other terminations, and workers’ compensation cases will all be evaluated to determine if there is discrimination.

It’s important to note that employers still have the ability to act against an employee with reason. After a workers’ compensation claim, employees who fail to perform or show poor attendance records may be demoted, transferred, or legally fired.

What to Do if You Suspect Discrimination

If you suspect discrimination, do not show anger or say anything that could be misconstrued if a lawsuit goes to court. Talk with an attorney as soon as possible. You may need other employees to serve as witnesses to the behavior. Try to document any letters, conversations, or situations that may prove to be discrimination.

Possible actions against your employer may include a case in a workers’ compensation forum as well as a lawsuit for general employee discrimination under the Fair Employment and Housing Act. Through a workers’ compensation forum, you may be entitled to receive as much as 50% more compensation or $10,000 if you can prove discrimination.

Don’t be afraid to speak out if you suspect you or your coworker is being discriminated against in a workers’ compensation claim. Every employee has a right to receive compensation for work-related injuries and illness, and discrimination will not be tolerated in the courts. A knowledgeable workers’ compensation attorney at DiMarco | Araujo | Montevideo can help you determine how to move forward with a discrimination case against your employer.

Taking action will not only improve the working environment for other employees just like you, but will ensure you receive the compensation you deserve to move forward after an accident. Please let us know today if you suspect discrimination in your workers’ compensation case.

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