Why Would an Employer Dispute a Workers' Comp Claim?

Often, the answer to why an employer would dispute a workers' comp claim is simple and boils down to a single five-letter word: money. Employers pay premiums to provide workers' compensation benefits to workers. (In most states, this is mandatory.) Premium amounts are directly affected when injured workers file for benefits. That means employers have an incentive to minimize claims.

In addition to financial reasons, employers might dispute claims based on skepticism about certain types of injuries or diseases, such as carpal tunnel syndrome. Or they might dispute a claim simply because they don't like the employee who filed it, or because they believe remote employees shouldn't qualify for workers' comp.

We'll discuss all of these reasons below.

Rising Premium Costs

Logically, the more workers' comp claims that are filed, the higher the costs for employers. Workers' comp insurance premiums increase when more workers than estimated file for claims, or when an employee has a particularly expensive claim (for instance, requiring back surgery). It is for this reason that employers and their insurance companies routinely use investigative agencies to monitor the daily activities of workers who have filed workers' compensation claims.

If you're filing a claim for workers' compensation—particularly if your claim isn't a very strong one—don't be surprised if your public activities are monitored. That could include an investigator parking outside your house for a few hours to see whether you really appear injured. Investigators have also been known to observe claimants as they attend medical appointments.

If your doctor has placed you on restrictions in terms of lifting, walking, or anything else, be sure to abide by those restrictions. Similarly, if you've been prescribed an assistive device, use it and bring it to your medical appointments.

In practice, employers usually don't object to claims that are clearly legitimate. Doing so only wastes their time and money and breeds staff resentment. Unless an employer has a bias or personal animus against their employee, they usually have little reason to challenge well-supported claims.

For borderline claims, as in the case of an office employee who develops lower back pain allegedly due to extended periods of sitting, some employers will challenge these and some won't. Employers must weigh the costs of paying the claim versus potentially poisoning a relationship with a valued employee.

Employer Skepticism of Certain Medical Conditions

Unfortunately, many employers don't believe that some injuries are serious or even valid, especially cumulative trauma injuries. They assume that a worker who files for workers' compensation benefits on the basis of carpal tunnel syndrome, for example, is not being completely truthful (or is "malingering," the industry term for feigning sickness or disability for financial gain).

Employer bias is particularly strong against injuries involving inexplicable pain that cannot be wholly verified by medical examination, or even sufficiently verified by x-rays, other imaging, or nerve conduction studies. Does this mean that the injured worker who has constant back pain is malingering? Definitely not. Many medical conditions are difficult to objectively verify.

Dislike of Employee or the Law

Employers might also have personal animus against certain employees, and treat any claim brought by them as automatically suspect. Of course, you're entitled to workers' comp whether or not you have a good relationship with your employer, so don't hesitate to pursue your claim.

In addition, with remote working more popular than ever, some employees are filing workers' comp claims based on injuries that happen at home. Make no mistake: most states allow these sorts of claims as long as the injury is work-related. For example, carpal tunnel syndrome could easily develop in the course of one's employment, even while working from home. An employee who falls down the stairs will have a much harder time proving their claim, even if the fall occurred during work hours.

Common Reasons Workers' Comp Claims Are Denied

If your employer or its insurance company denies your claim, or any part of it, it should inform you in writing. Typical reasons given for denying a claim are:

• You didn't suffer a serious injury.
• Your injury didn't take place during work, or within the scope of employment.
• You don't need medical treatment for your injury.
• You don't need time off work for your injury.

Fighting a Denial of Workers' Compensation Benefits

If you receive a notice that your claim has been denied, call or write to your employer's workers' comp insurance carrier. If this doesn't solve the problem, hire a workers' comp lawyer and request a hearing with the state workers' comp board.

The bottom line is this: employees who have become injured or sick as a result of their job should file for workers' comp to protect themselves, and if their claim is denied, they should fight the insurance company, with the help of a lawyer.

Whether or not the employer believes that the worker is legitimately injured will turn out to be irrelevant, and the worker shouldn't worry about whether the employer holds the employee in contempt for filing a claim.

It is the worker's right to have time off work and medical treatment paid for; the worker has given up the right to sue the employer in exchange for the workers' comp benefits and should not feel guilty about using them.

Also see what to do if your employer retaliates after you file for workers' comp.

Contact a Workers' Comp Lawyer

As an employee, don't be deterred by your employer's objection to your claim. If you have a legitimate claim and your employer is disputing it, hire a workers' comp lawyer to help you.