Why Are Some Workers’ Compensation Claims Denied?
In South Carolina, injured workers have compensable workers’ compensation claims if their injuries were the result of “. . .an accident arising out of and in the course of their employment.”
South Carolina workers’ comp cases are handled through an adversary system of justice. The theory is that the process of the employee and the employer each arguing their side of the dispute in front of a neutral workers’ compensation commissioner will reveal the truth.
Therefore, a decision by an employer or insurance company to reject or deny a workers’ comp claim is not necessarily the end of the story. Some denials are certainly valid, and not every workers’ compensation claim can be won; however, in other situations where a worker’s injury claim is rejected or denied, it turns out that the worker is actually entitled to workers’ compensation benefits. Our law firm regularly analyzes the cases of injured workers who claims have been rejected or denied by workers’ comp insurance companies. In many of these cases, we are able to obtain money and medical care for the injured workers. Sometimes, we are able to get benefits for our clients quickly. In other situations, we have to pursue litigation to get our clients the payments and medical care they are entitled to receive.
Every workers’ compensation case is different, and countless reasons exist why an employer or insurance company might reject or deny a workers’ comp claim. Here are some of the more common areas of dispute:
Aggravations of Pre-Existing Conditions
Many workers have pre-existing conditions, due to a prior injury or a degenerative condition. Under South Carolina law, if work activities aggravate a pre-existing condition, the worker is entitled to receive money and medical care for the aggravated condition.
In many cases involving aggravations of pre-existing conditions, a disagreement occurs about whether work aggravated the condition or whether the condition was just naturally worsening on its own. In order for injured workers to receive compensation for aggravation of a pre-existing condition, they will frequently need supporting expert testimony from a physician, and the dispute will have to be litigated.
In some aggravation cases, no single incident–such as the worker falling or being struck by a piece of machinery–caused the injury. Rather, cumulative trauma on the job, over a long period of time, caused the aggravation. South Carolina law does recognize and provide compensation for work injuries resulting from cumulative (or, repetitive) trauma. Proving a cumulative trauma injury will, again, often require obtaining and presenting expert opinions at a hearing before the South Carolina Workers’ Compensation Commission.
Disagreements Over Whether the Injury Actually Occurred at Work
In some cases, the employer disagrees that the worker was injured on the job. For example, the employer may believe that the worker is lying and that he or she was actually injured while he or she was off work. This type of factual dispute tends to require litigation in order to resolve it, especially if no witness or surveillance footage is available to support the claim.
Is The Injured Worker an Employee of the Employer?
A fundamental requirement for all workers’ compensation claims is that an employee-employer relationship exists at the time of the injury. Some employers require their workers to sign a written agreement that they are not an employee or the employer or the employers call the workers “independent contractors,” even though they are actually employees. Written agreements can be a factor in deciding whether an employer-employee relationship existed, but they are not conclusive.
Disputes about whether an employee-employer relationship existed at the time of a work injury most frequently come up in the trucking and construction industries. Examining several factors is important to determine whether the injured worker is an employee of the employer including:
- Who gets the projects on which the worker works;
- Who provides the tools necessary to perform the work;
- Who provides the materials necessary to perform the work;
- Who determines when the worker arrives at work, leaves work, and takes breaks;
- Who can hire/fire the worker; and
- Whether the worker is paid by the hour or by the job
Over the years, workers’ compensation commissioners have issued hundreds of decisions that help refine and provide precedent for how the Commission determines and interprets the above control factors. Each case is very different and has to be analyzed carefully to determine whether the injured worker qualifies as an employee who is entitled to workers’ comp benefits.
Did The Injury Arise Out of Employment?
The phrase “arising out of employment” is very short, but it has also resulted in extensive litigation. The general rule is that an employee must be able to establish that a connection exists between the injury and some aspect of the employment.
Did The Injury Arise in the Course of Employment?
In order to prove that the injury arose “in the course of employment,” employees generally have to show that they were injured while furthering the employer’s business or doing a task that is common to their job; however, it is not necessary for employees to show that they were performing actual work activity at the moment they were injured.
The types of disputes that come up regarding whether an injury was “in the course of employment” include issues such as:
- Generally speaking, during an employee’s commute to and from work they are not covered by workers’ compensation insurance; however, exceptions exist. In contrast, once the employee is on or about the premises workers’ compensation insurance coverage generally applies.
- The specific facts about how an employee was injured during a meal or break are critical to determining whether workers’ compensation insurance coverage applies during those times.
- An amazing number of cases involving injuries while employees were going to the restroom exists. Again, the specific details surrounding the injury make a huge difference in determining whether an injury during a restroom break is covered by workers’ compensation insurance.
- Employees who are injured while voluntarily engaged in horseplay during work frequently are not entitled to receive workers’ comp benefits. By contrast, a worker who is a non-participant in the horseplay, but who was injured, will generally be allowed to receive workers’ compensation benefits.
- Many workers have to travel as part of their job. Injuries during such travel are generally covered by workers’ comp; however, if a worker deviated from his work travel to pursue a personal errand, then the possibility exists that no coverage will be available for an injury that occurs during the deviation. Cases involving deviations from work travel are some of the most complex cases that come up in the South Carolina workers’ compensation system. The specific nature and extent of the deviations become critical in determining whether the injured worker will receive workers’ comp benefits.
Did the Injured Worker Provide Notice Within 90 Days of the Injury?
South Carolina law requires employees to give employers notice of work injuries within 90 days of the injuries’ occurrence. If an injured worker fails to provide notice to the employer within this time frame, then the injured worker is not entitled to receive workers’ comp benefits unless the injured worker had a “reasonable excuse” for failing to report the injury at work within 90 days.
The best practice for a worker who was injured on the job is to give very specific notice to the supervisor about the injury and that work caused the injury; however, South Carolina courts have ruled that an employer’s “constructive notice” is sufficient. The details of constructive notice are critical, but in some cases the claim of a worker who has not given clear notice of the injury can be saved. Several exceptions also exist that can extend the 90-day notice period.
Was the Injury Caused by Intoxication?
If a worker was intoxicated by drugs or alcohol and the intoxication was a substantial factor in causing a work injury, then the injured employee may not be entitled to receive workers’ compensation benefits. In circumstances such as this, the burden shifts to the employer/its insurance carrier to prove the intoxication was the cause of the injuries. Intoxication, alone, does not bar an injured worker’s claim to workers’ compensation benefits.
Conclusion
As mentioned above, the instant article outlines just some of the most common issues that lead employers to deny workers’ compensation claims. Every case is different, and our team analyzes the facts and relevant law to determine whether we can obtain benefits for our clients.
If you believe you have been injured on the job, but your claim has been rejected or denied, you can call the Law Office of Mary E. Jordan, LLC at (843) 689-9565 to discuss your case. We do not charge for the consultation to determine whether you potentially have a valid workers’ compensation claim, and you are not obligated to hire us. In fact, if you do hire us, we get paid by taking a percentage of what we collect for you, so you do not have to pay us money up front or along the way!
