Every state has a workers’ compensation program in place to provide benefits to those who are injured while on the job. These benefits include medical care, lost wages, specific loss benefits (such as losing a limb, loss of eyesight, or disfigurement), and, in the event of a fatality, death benefits.
Pennsylvania’s workers’ compensation system is a no-fault system. This means that if you meet the other requirements, you are eligible to receive benefits even if you were at fault for the accident. You do not have to prove that your employer or someone else was at fault.
However, not every case is automatically approved. Your employer or the workers’ compensation insurance company may deny the claim. Employers are especially wary of workers’ compensation claims and may try multiple defenses in order to avoid paying any benefits.
This means that your workers’ compensation claim may be denied, or at best, delayed. If your claim is denied, you will likely need assistance from a workers’ compensation lawyer. A lawyer can protect your rights and help you prove your claim so you can get the benefits you deserve. Read on to learn more about the workers’ compensation benefits process and the various defenses that your employer might use to strip you of benefits.
How Do You Get Workers’ Compensation Benefits?
The Pennsylvania Workers’ Compensation Act provides benefits to pay for medical expenses caused by a workplace injury or illness. You must be injured while performing job-related duties.
You should ideally report the injury as soon as possible. Let your employer know when and how the injury occurred. If you wait too long, your claim may be denied.
While the workers’ compensation program does not require that someone be at fault in order to receive benefits, the employer has the right to deny the claim. However, the claim cannot be denied without good cause. The employer must have a solid reason why you should not be entitled to benefits. If your workers’ compensation claim is denied, you have the right to file an appeal and have your case heard before a workers’ compensation judge.
The judge will decide regarding your claim. You may wish to have a lawyer help you prepare for your case and help you find evidence that will prove your case.
What is Employer Defense?
Workers’ compensation employer defense involves the use of defenses to keep injured workers from receiving their benefits. There are many common defenses that an employer may use to deny your workers’ compensation claim. They include the following:
#1 Intoxication from Drugs or Alcohol
This is a common workers’ compensation employer defense. Employers do not have to pay benefits to those who are injured while under the influence of drugs or alcohol. However, proving this can be difficult. It is best to get sufficient evidence, such as medical tests, proving that the person had drugs or alcohol in his or her system at the time of the injury. The tests would have to be done right away in order to ensure accuracy.
Witness accounts may also prove helpful. If someone saw the employee drinking alcohol or doing drugs before the accident took place, that would be helpful evidence. Otherwise, the behavior of the employee may be able to be used as well. If the person was walking erratically, bumping into things, slurring their words or had a glazed look in their eyes, those are signs of intoxication that could use as evidence.
#2 Self-Inflicted Injuries
The workers’ compensation program is in place to help those injured by workplace injuries that are accidental. However, some employees go as far as to hurt themselves intentionally and blame the injuries in a workplace accident in an attempt to claim workers’ compensation benefits. This is fraudulent activity and will result in benefits being denied altogether. However, the employer has the burden of proving that the injury was intentional and caused by the employee.
#3 Horseplay and Reckless Behavior
If the employee was engaged in misconduct or was displaying reckless behavior at the time of the injury, then the claim can be denied. The employer can review surveillance footage or get eyewitness accounts to confirm how the injury occurred.
#4 Idiopathic Medical Condition
Sometimes medical conditions occur suddenly without warnings, such as a stroke, seizure, or heart attack. Because these incidents can occur outside of the workplace at any time, it is up to the employee to provide sufficient evidence that the medical event was caused by the work environment. This may involve a thorough assessment of medical records and testimony from doctors. If a link to the medical condition and employment cannot be proven, then the employer can claim that the event was not work-related.
The injury must occur during the course of employment in order for workers’ compensation benefits to be paid. The injury can happen at any location—it does not need to be at a central office, for example. Since many people now work from home, the injury can even happen at home. However, it must be proven that the person was engaged in work activities when the injury occurred. If the person tripped over a dog while answering a work call, that would likely be a valid claim. However, if the person was knocked over by their dog after work hours, then that would not be a valid claim since the injury did not arise from performing duties related to employment.
Looking for Specifics
Each workers’ compensation claim is unique. Even if your case has been denied or seems outlandish, you should contact a lawyer anyway. There have been atypical cases involving dogs, canoe trips, and even bears, and they were successful after an appeal. A lawyer can help look for specifics in your case that can be used as strong evidence.
For example, in one case, a man was injured during horseplay. While typically horseplay is not a valid reason to receive workers’ compensation benefits—since it indicates reckless behavior—the man was not actively engaging in the horseplay when his injury occurred. Since the managers and supervisors were also engaged in the horseplay—which occurred during a company team building event—the horseplay was done during the man’s employment and done with management consent. In the end, the man was awarded workers’ compensation benefits.
As you can see, there are often loopholes in the law. Do not miss out on the benefits you deserve. Even if your employer has a defense, you should consult with a lawyer who can help you formulate a defense of your own.
Get Help from a Workers’ Compensation Lawyer
If you have filed a workers’ compensation claim, your employer may try to deny it. There are many defenses available to employers, and they may use every single one to avoid paying out benefits. In many of these case, the employees were genuinely injured on the job and desperately need this money to pay for medical bills and lost wages.
The team of workers’ compensation lawyers at Krasno Krasno & Onwudinjo can help you if your employer has denied your claim. We have been serving Philadelphia since 1936. Contact us today at 800.952.9640 or online to find out how we can help. A free consultation will help ensure that you understand your legal rights.