Why Workers’ Compensation Claims Are Denied

by | Published on Sep 19, 2016 | Workers Compensation

Workers’ Compensation claims are often denied on various grounds. Medical records play a very important role in helping to determine the nature and extent of the employee’s injury. It is on the basis of a comprehensive medical records review that the worker’s eligibility for benefits is finalized. In case a claim is denied, the employee can file an appeal.

The injured worker has to notify the employer immediately if he/she sustains an injury while at work and must ensure that the employer is given all the details. An injury may not be automatically accepted as work related by the worker being just present at work. The injury must arise out of the work-related duties and the employee must be cautious enough to report the specific duties that he/she feels caused the injury.

In one particular workers’ compensation case involving a Walmart employee, the Judge did not find that the applicant had an occupational claim that was compensable because her medical records did not support the testifying doctor’s opinion that her condition was related to a progressive occupational condition. The employee had filed a claim for an accident that occurred in April 2010 when she was working with Walmart. She was at her workplace and was simply walking in the store when she felt a “pop” in her low back. Some time earlier, she was doing some lifting work in her position as a zone merchandise supervisor. She reported the accident to her manager. Her family doctor diagnosed her with protruding lumbar discs, and she took a leave of absence while she received treatment for the same. Walmart’s official workers’ compensation carrier did not authorize any treatment.

This employee filed two claim petitions, one for the specific accident that occurred in April, and an occupational claim claiming that the work she engaged in from December 2008 through April 2010 caused her back injury. Walmart denied both claims, following which the employee filed a Motion for Medical and Temporary Disability benefits with the Workers’ Compensation Court. The judge who heard the Motion ruled in favor of Walmart on both claims. On appeal, the Appellate Division also ruled in favor of Walmart. The Appellate Division thought the Workers’ Compensation judge’s findings well-reasoned and said that the judge reviewed the applicable case law and applied the two-step “positional risk test” to determine if the injury occurred due to the nature of her work at Walmart.

  • The first part of the test required the petitioner to prove that the injury would not have happened “but for” the fact of employment.
  • The second part comprised analyzing the “nature of the risk” that caused the injury.

The Court found that the employee failed to meet the first part of the test because it could not be established that she would not have been exposed to the risk if she had not been at work. The back injury could have happened even while she was not at work. Moreover, it could not be proved that something related to the workplace contributed to her injuries.

Legal experts feel that the petitioner may have had a better chance of proving her case if she had reported her earlier lifting activity at the cash register before walking and feeling the “pop,” and related it to the back pain when she first reported the claim.

What are the various reasons by which a workers’ compensation claim may be denied?

  • The injury did not occur at work
  • The employer was not notified of the injury within the required time (i.e. at the earliest possible)
  • The petitioner was intoxicated (under the influence of alcohol or drugs)
  • He/she was not treated by an approved medical provider
  • He/she never received medical treatment
  • The claim was not filed on time
  • The injury is from a pre-existing condition

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