When a worker is injured on the job, the workers' compensation system is intended to ensure that the worker receives the medical treatment necessary to recover and financial support for the resulting time away from work. However, this compensation is ultimately provided by an insurance company — and insurance companies generally seek to avoid paying out claims when possible. Accordingly, these companies rely on a number of common, well-established defenses to avoid paying claims.
Workers' compensation claims fall into two categories: accidental-injury claims and occupational-disease claims. The defenses that an employer's insurance company might assert to avoid providing compensation for an injured worker often depend on the type of harm sustained.
Defenses to Accidental-Injury Claims
For an injury to be deemed "work related" and therefore compensable, it must occur within the course and scope of the employment. The workers' comp insurance company may deny a claim alleging that it was not work related because it did not occur while the worker was performing his or her duties, or as a result of performing these duties. The worker must also be a covered employee — independent contractors are not eligible for workers' compensation benefits.
Assuming that all of these conditions are met, though, an employer may still asset a number of defenses to compensation:
- Horseplay: In some states, horseplay is a valid defense to workers' compensation. In Pennsylvania though, a worker may still be eligible for workers' comp benefits, as long as the horseplay is not so disconnected from the injured worker's regular work duties as to render the worker essentially a trespasser.
- Willful misconduct: When an employee engages in willful misconduct, the employee becomes ineligible for workers' compensation benefits. However, an injured worker may contest the claim that the behavior rises to the level of willful misconduct.
- Intentional or self-inflicted injuries: Under Pennsylvania law, a worker is not eligible for compensation if the worker's injury is intentionally self-inflicted. The employer bears the burden of proving that the injury was self-inflicted and intentional.
- Intoxication or illegal drug use: In Pennsylvania, if an injury would not have occurred but for an employee's intoxication or illegal drug use, the injured worker is not eligible for benefits.
- Idiopathic condition: An employer may argue that a condition is idiopathic, meaning that the condition arises spontaneously or from a cause that cannot be identified (such as a seizure or a heart attack). If the cause cannot be identified, the employer may argue that it is not a work-related injury.
Defenses to Occupational-Disease Claims
Over time, some occupations result in illnesses. Occupational diseases include ailments, disorders and illnesses that develop gradually over time and are an expected result of working under the conditions inherent in the employment. For example, a worker who faces prolonged exposure to particular chemicals or irritants may develop asthma.
In such a case, because the ailment does not develop from one specific incident, a worker has to demonstrate the causal connection between the work activities and the resulting harm.
- Not causally related to employment: Often the employer's primary defense in occupational disease claims is that there is no causal connection between the work activities and the resulting injuries. The injured worker must demonstrate the causal connection with unequivocal medical testimony.
Defenses to Any Workers' Compensation Claim
When pursuing any workers' compensation claim, timing is critical. The failure to provide timely notice to an employer or to file a claim before any legal deadline can eliminate any access to compensation an injured worker may have had otherwise.
- Failure to provide notice to employer: An injured worker must notify his or her employer within 120 days of when the worker should have known of the injury or disease. When notice of a work injury is not given within 120 days, the claim for compensation will be normally be denied under Pennsylvania law.
- Statute of limitations: Under the Workers' Compensation Act in Pennsylvania, an injured worker can bring a claim up to three years after the date of injury. After three years the claim disappears, unless the injured worker can demonstrate that this period was extended for some reason.
Pennsylvania is among the best states in the country when it comes to protecting the rights of workers through workers' compensation — but this alone does not ensure that any individual worker's rights are protected. If you or someone you love has been injured on a job, discuss your case with a knowledgeable workers' compensation attorney.