Common Workers' Compensation Defenses

Workers’ compensation is a system of laws and procedures within which employees are entitled to receive benefits from injuries sustained in the course of their employment or in their line of duty in employment set up.

It is required under the law for every employer to have some form of insurance for their employees or workers in order to cover for injuries caused to the employees in the line of duty. Thus, workers’ compensation is a form of insurance cover that is mandated by the state, entitling every worker the right to compensation for every injury or disability related to his/her work.

Workers’ compensation is important and beneficial to both the employee and the employer. To the employee, the law requires that the he/she receives some form of benefits or compensation for work-related injuries without having to go through the tedious legal process or litigation against their employers.

To the employers, the law is also a protective shield in that it limits the amount an employee can claim under the workers' compensation from injuries caused during their line of work. It also prohibits the employee from suing his/her co-workers. The system also prohibits the employee from pursuing a legal suit against the employer that can cause the employer a bad reputation or loss for damages awarded to the employee.

With this information in mind, it is essential to note that legal disputes might arise between the employee and their employer (or even insurance companies) concerning the benefits or compensation claims. A common scenario is when the latter fails to give compensation to their employee. In turn, they can use several defenses as to why they didn’t give the required compensation.

While the law protects workers from being denied the right to claim for compensation from their employers for injuries caused during their course of duty, the law further allows employers to defend themselves against any claims by the employees. The employer is, therefore, allowed to defend themselves in order to diminish his/her fault to an extent, making the employee take up some burden or fault for the injuries done. These defenses are discussed below in detail.

Failure of the Employee to Give Notice to the Employer

California workers' compensations laws require employees to provide their employers with a notice for injuries they have sustained at work. According to California Labor Law section 5400, an employee is required to give notice to his/her employer regarding the injury within 30 days from the date of the injury. This notice can be given to the employee’s immediate supervisor or line manager. Section 5401 of the Labor code further provides that after the employer has received the notice of injury, he/she is required by the law to give the employee a claim form to fill out for purposes of claiming for compensation. This claim form should be provided to the employee within one day of receiving the notice of injury. However, if the employer fails to provide a claim form to the employee, the employee can still seek the form from the nearest workers' compensation board in the state in which they reside. This claim form is then taken to the insurance provider to cover for the outlined injuries.

The process of claiming for compensation all starts with the employee. This means that the failure of the employee to undertake the necessary process of notifying his/her employer of the injury or accident sustained at work might deny them the chance to be compensated for the injuries suffered. If an employee fails to do this as required, the employer can hold or refuse to give out the compensation.

The employer can use this as a defense in withholding any form of compensation meted out to the employee. He/she can also reduce the amount meant to be given to the employee in this defense of the employee’s failure to give out notice of the injuries. Therefore, as an employee, ensure that you observe all the steps of notifying your employer of your intentions to seek compensation.

An Injury That is not Linked to the Employment

Workers' compensation benefits cover for injuries or accidents within the scope of the employee’s work-related duties. Injuries sustained outside the scope of the employee’s work duties might not qualify for a worker’s compensation benefits cover. In determining this, a lot of questions need to be answered; for example, what constitutes an employee and what type of injuries are considered as work-related injuries?

Workers' compensation laws require the employer to provide a worker’s compensation coverage to all their employees. These are persons employed under them. However, certain people are excluded from workers' compensation. These include business owners, independent contractors, volunteers, employees on private homes (nannies, baby sitters), farmers and farm hands, maritime employees, casual workers, and railroad employees. 

Injuries should also be determined as to whether they are injuries covered under the workers' compensation insurance coverage. Injuries resulting from mental and psychological strain due to work stress, working under too much pressure, and an overbearing boss are considered injuries.

Death threatening diseases such as cancer that are as a result of being exposed to toxins at the workplace are also covered under the workers' compensation insurance cover. An employer is responsible for neglecting to provide protective measures to his/her employees against dangerous toxins at the workplace causing the employee to be exposed to toxins that can cause life-threatening disease. Such diseases are liable for workers' compensation.

Injuries caused by work facilities such as machines, chairs, tables, stairs are covered under the workers' compensation insurance. There are injuries which are also sustained during work sponsored activities such as workshops and training and team building; such injuries are considered to be work-related injuries and are, therefore, covered under the workers' compensation cover.

Conditions that are aggravated by workplace conditions such as back pains, headaches, and muscle sprains are also considered work-related injuries.

The employee bears the burden of proof to show that his/her injuries are indeed work related. The above factors shall, therefore, be considered by the employer in putting up a defense. The employer can argue that the worker does not fall under an employee in the State. The employer can also argue that the injuries caused on the employee are not work related injuries.

When Employee is Unable to Determine the Cause of Injury

As discussed earlier, the workers' compensation benefits compensate employees who have suffered from work-related injuries. The Employee is subjected to a test to show that the injury was caused while at work. However, there are some injuries that can occur at work by factors not related at all with employment.

Determining the cause of the injury is always important for one to process a workers' compensation claim. The employee must show that the accident or injury suffered was indeed work related. Usually, an independent medical examination must be done to establish if an injury was caused by factors related to the employee’s employment. Employee’s background medical history can always be investigated to determine whether the employee has been suffering from certain conditions that led to the existing injury. Cases such as heart attacks and seizures are just but a few cases where a full examination must be conducted to determine the medical history of the employee.

Employers use this as a defense when the employee cannot fully determine whether the injury they suffered is related to their work. Lack of knowledge can be used by the employer as a defense. 

Willful Negligence or Horseplay

Most employers have set rules, guidelines, or policies for their workplaces. Employees who engage in reckless behavior while at work might suffer the consequences in case of any injury suffered by them. Where an employee violates any of such workplace rules, the employer can use this as a defense, claiming that the injury was caused when the employee was in violation of workplace safety regulations. Some reckless behavior includes coming to work while intoxicated, smoking near a machine, failure to wear protective masks in a factory and so on. Employees who also engage in quarrels and fights at the workplace that result in injuries are also not compensated for such injuries.

Injuries sustained in violation of company policies may deny an employee his/her compensation benefits. An employer will use such defense in claiming that the employee behaved recklessly while violating the company’s policies and regulations, and therefore, any injuries inflicted upon him/her cannot be burdened upon the employer.

Not Attending Doctor’s Appointments

California labor code provides payments and benefits that are portioned to an injured employee or claimant. An employee cannot make a claim if he/she has not visited the doctor to have the injuries assessed and determine the extent of the said injuries. An injured employee is required to seek medical attention for injuries sustained. The doctor who attends to the injured employee is meant to conduct a medical examination and write a report outlining the seriousness of the injuries on the employee. This report is the one which the employee will use to claim his/her benefits.

According to various sections of the California labor code, there are certain payments that are accorded to the employee, and these payments are made after assessing the medical report from the doctor attending to the injured employee. A medical report will determine the amount paid to the claimant from bills covered in medical treatment, hospital services, lab tests, x-rays, doctor’s visits, medicine and so on. A medical report will also determine the extent of the injuries and whether they are permanent or temporary. Permanent injuries resulting to inability to continue working will determine the amount paid out to the employee; temporary injuries will determine the amount paid to the claimant for the time spent out of work. 

An employee who fails to attend doctor’s appointments risks losing their benefits from the workers' compensation cover. The employer can use this as a defense against the employee, arguing that a medical report is not available to show the extent of the injuries sustained and hence, the insurance company is unable to calculate the amount due to the employee.

Injuries are Not as Bad as They are Claimed To Be

An employee who fails to show up at work or fails to perform their usual duties on the claim that they suffered injuries, but upon examination, evidence show that the injuries are not as bad as they claim, they risk having the benefits reduced or denied altogether.

Intentional or Self Inflicted Injuries

There are employees who inflict injuries upon themselves in order to claim for company benefits. Employers use this defense to show that an employee is trying to defraud the system. Injuries which are sustained by an employee intentionally in order to make a fraudulent claim can deny the claimant compensation. Fraudulent claims itself subject the employee for a legal suit by the employer or subsequent dismissal.

Workers' compensation is meant to cover injuries sustained by an employee resulting from an accident at the workplace. However, if an employer can show that the injury suffered by an employee was actually self inflicted in order to gain some benefits from workers' compensation or get time off work, then an employee may be denied workers' compensation benefits.

Statutory Limitations

It is a requirement by the law that suits and claims should be filed within the stipulated statutory time limit. The statute of limitations generally provides for a time limit in filing suits. Each state has a time limit in filing workers' compensations claim. The time limit in California typically ranges from one to three years. Furthermore, the law requires that a claim is filed within a year from the date of the work-related injury. Failure for the claimant to file his or her claim within the statute of limitations will void their ability to recover for injuries sustained.

Injury Caused by a Pre-existing Condition

An employee might be suffering from a pre-existing condition which gets worse if aggravated. An employer might argue that an employee’s injury was caused by a pre-existing condition that is not necessarily related to their work.

If it can be proved that the employee’s injury was caused by a pre-existing condition, then the employer can request to have the workers' compensation benefits reduced or denied altogether.

However, if an employee suffers from a pre-existing condition, and their usual work causes an aggravation on the same condition, then the employer is liable to pay compensation on the aggravation caused. The employer might, however, argue to have the benefits reduced on the claimant since the injury suffered was not solely a work-related injury.

The above defenses are meant to deny claimant benefits given to them under the workers’ compensations laws. A claim might be denied or the benefits accorded to the claimant reduced. So what other options does the claimant have once a claim has been denied?

If a claim has been rejected, the claimant has the right to appeal. A claimant has the right to have the claim heard by a judge. The claimant can file an application for adjudication of claim with all the required documents including medical reports and his/her journal of what he/she has suffered as a result of the injury. The claimant should also give notice to the other parties involved, including the employer, and file for declaration of readiness to proceed. If the claimant still disagrees with the decision of the judge, they can still file for a petition for consideration.

There are also available sanctions for an employer who as has failed to provide a worker’s compensation coverage for the employee. These sanctions include fines, criminal prosecution, the personal liability of the employer for any workers' compensation benefits due to the employee, or the right of the employee to sue instead of filing a workers’ compensation claim.

The claimant also has the option of suing his or her employer for injuries suffered at workplace. If this is successful, the court may award a wide range of damages to the claimant including punitive damages, medical expenses, lost wages, pain and suffering, and mental distress.

Even though the workers' compensation bars the employee from pursuing any legal suit against the employer, there are some exceptions where an employee can seek legal redress in a civil court. 

An employee can bring a civil suit under tort if the employee believes that the employer intentionally caused the harm. Common intentional torts include:

• Assault for an attempted battery or threat to commit battery
• Battery for injury caused to a person including being hit by someone
• False imprisonment, where one has been confined against his/her will or any legal authority
• Intentional infliction of emotional distress, where one has been traumatized by certain acts or conducts
• Fraud, where you can show that someone eluded to you and those actions caused you some form of injuries
• Defamation, where there have been false statements about you either at the workplace, and those false statements have caused you some form of injury such as personal reputation
• Invasion of privacy. This is where private information of someone has been exposed to the public at the workplace and this information has caused the employee some injury
• This is where one enters another person’s property without any form of permission
• Conversion, where someone at the workplace takes your property and makes it their own

An employee also has the right to sue other parties other than the employer if he or she reasonably believes that the injury sustained was inflicted by someone other than the employer. This can include assault by a co-worker while at work and injury by defective equipment which the equipment manufacturer was aware of. The employer and the insurance company can also enjoin themselves in the suit filed by the employee to claim for paid workers' compensation benefits.

Workers' compensation is a system that requires employees to access their benefits from work related injuries through an administrative process. An employee who believes that his or her right to access benefits through workers' compensation system has wrongfully been denied is allowed to pursue a legal suit. This is however admissible after it is proved that the claimant has exhausted all the statutory administrative process. The claimant then has the right to seek legal redress in a civil suit.

The workers' compensation laws is a system that provides the process and legal procedures within which one can claim benefits from injuries in the workplace. This legal system can, however, be confusing and difficult for an employee who does not know what is rightfully entitled to them. It further gets challenging where the employer puts up these defenses in pursuit of denying the claimant the benefits or compensation. The The Workers Compensation Attorney Group is available to offer expert legal advice to employees whose employers have failed to give them workers' compensation. We offer our services in and around Long Beach, CA. Get in touch with us at 888-888-8888 and talk to one of our lawyers for a complimentary case evaluation.