What Happens if a Workers' Compensation Claim is Contested?

Employers are typically required to have workers' compensation insurance. This coverage compensates workers for lost wages if they are injured in a work-related accident.

Many workers are surprised to learn that their employers can dispute the validity of their workers' comp claims. In some cases, the dispute ends in the employer's favor because the worker did not have a valid claim.

What Types of Injures are Covered Under Workers' Compensation?

Broadly speaking, injuries that are connected to employment requirements and/or conditions are covered under workers' compensation.

A restaurant server who develops lung cancer because of exposure to second-hand smoke in the restaurant would likely be covered under workers' comp. The same would apply to a receptionist who develops carpal tunnel syndrome due to extensive hours of computer work.

Most injuries that occur in the workplace are covered by workers' comp, but employees may also be eligible if an injury occurs while using a company vehicle or outside the workplace if the activity was directly related to the job.

Injuries that occur during work breaks may also be covered if they occur in the company cafeteria, break room or on company-owned properties.

Are You Covered by Workers' Comp?

Most – but not all – employers are required to have workers' compensation insurance, and not all workers are covered.

Only workers who are classified as employees can be covered. Independent contractors, for example, would not be covered.

Some states do not require coverage for illegal workers, while others do.

Certain types of workers are also not covered by workers' compensation, including:

  • Agricultural workers
  • Domestic workers (babysitters, housekeepers, etc.)
  • Seasonal workers

Each state has its own laws and regulations regarding workers' compensation. In some states, employers must have a certain number of employees before being required to have this type of insurance, while other states require it even if the employer only has one employee.

What Happens if a Workers' Compensation Claim is Contested?

It's not uncommon for employers to contest workers' compensation claims. Employers have every right and an incentive to dispute any claims they feel are invalid.

Just like with any other type of insurance, an employer's premium will increase if a claim goes through.

When employers dispute a claim, the workers' compensation board will open an investigation and review the claim before making a decision.

During the investigation phase, employees are typically sent to a physician for an evaluation. In this type of scenario, doctor-patient confidentiality is non-existent, but doctors are supposed to remain neutral.

Because there is no doctor-patient confidentiality, statements made by employees during the exam can be used by employers to support their case.

If the workers' compensation board rules in the employer's favor, the next step is the appeals process. The appeals process usually starts with a hearing with an administrative judge. Further appeal can be taken to a review panel and finally, state court.

Workers' compensation claims can also be denied for a variety of reasons, including:

  • Lack of evidence that the injury was work-related
  • The employee failed to get medical care
  • The claim was not filed in time
  • The injury was not reported in time

Some claims, like those for stress-related injuries, are difficult to prove and are more likely to be denied.

If a workers' compensation claim is denied, the employee may want to consider seeking legal counsel to navigate the appeals process.

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