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Employer Defenses Against Workers’ Comp Claims

Employer Defenses Against Workers’ Comp Claims

This blog post was originally published on October 29, 2015. It has been updated as of January 9, 2018.

Although the nature of New Jersey Workers’ Compensation claims are typically faultless, there are some specific instances where the employer can forego paying benefits to injured employees. Even with a sound workplace safety program and injury prevention strategies in place, accidents do happen. However, before utilizing your mandated coverage, consider the nature of the incident and determine if any of the following defenses are applicable.

Lawyers.com states that while the Workers’ Compensation system doesn’t require a fault, it does not mean that any and all work-related injuries and illnesses are compensable. Therefore, the following reasons will be evaluated by the employer and insurance carrier.

Willful Misconduct or Horseplay

Employers can deny claims for Workers’ Compensation if the employee was injured as a result of violating safety policies and roughhousing, purposefully misbehaving, etc.

A certain amount of horseplay, or willful misconduct, can be expected in the workplace, regardless of job description or working conditions. However, it is important to remember that horseplay in and of itself cannot be used as a defense to a workers’ compensation claim. In the case of a horseplay-related work accident, both instigator(s) and victim(s) may be eligible for workers’ compensation claims.  Determining whether the inciting of willful misconduct constitutes a major deviation from work is the preferred focus of the courts when assessing a horseplay-related workers’ compensation case. If the petitioner is found to have deviated from their work duties to engage in horseplay, the employer may have a solid defense with which to deny the claim. As noted in Knight v. Liberty Mut. Ins. Co; “Where an employee steps aside from his or her employment and engage in horseplay… and accidental injury results… the injury is not one arising out of the employment within the meaning of the compensation act.”

Self-Inflicted Injury

Liability for the employer can be reduced or even eliminated if they are able to prove the injury resulted from self-infliction.

In regard to workers’ compensation claims, fault is not an issue. An employee who is injured on the job is entitled to claim workers’ compensation benefits no matter who is at fault in an accident resulting in injury. An exception to this rule, however, is in the case of a self-inflicted injury. Self-inflicted is defined as: “of a wound or other harm inflicted on oneself.”

The burden of proof falls on the employer to determine whether the self-inflicted injury was intentional or unintentional. An unintentional injury would be subject to workers’ compensation benefits, while an intentionally-caused self-inflicted injury would not. For example, if an employee punches a wall at work out of anger or frustration, the employer can argue that the injury was intentionally self-inflicted and can deny the claim. However, in this same scenario, the employee can claim “mental illness as a result of employment” lead them to injure themselves. In this case, a psychological evaluation would need to be performed to prove whether or not the employer is at fault.

Under the Influence

If the employee was under the influence of alcohol or illegal drugs at the time of the incident, the employer may use this defense to be relieved of Workers’ Comp obligations.

If an Employer believes their employee was under the influence at the time of a work-related accident, they can impose drug and/or alcohol tests on the injured employee and, depending on the results, may be able to deny that employee’s workers’ compensation benefits. However, there are some rules related to the drug testing and how the results can be used. The employers should already have clearly posted policies regarding drug testing. Also, regardless of test results, the employer should provide any emergency medical care that is necessary. Drug and/or alcohol tests need be administered as soon as possible after an accident and sent to a reputable lab for analysis in order to be considered in a workers’ compensation case.

Unrelated Causes

If the employee suffered injury or illness that occurred outside the terms of employment, they may deny paying benefits.

If an employee has a pre-existing condition, heart disease for example, and they have a heart attack at work, the burden of proof in this case would be on the employee and their legal counsel to show that the accident was related to employment. The employer may argue that the heart attack was unrelated to work, and that the employee could have experienced a cardiac event regardless of whether or not they were on the job. This means that the employee who suffered the heart attack will then have to prove that if it were not for the work that they were doing, they would not have suffered a heart attack.

Failure to Follow Procedures

In order for a claimant to receive benefits, proper procedures must be followed such as notifying employers immediately after an incident, following up with doctors, attending appointments, etc.

Further, if the employee makes a mistake in filing the claim, employers may be able to reject benefits altogether, as well.

It is also possible to deny liability for an injury on the basis of the “prohibited act” defense. In order to do this, the injury must have occurred when the employee violated a clearly stated, consistently enforced prohibited act, policy or rule.

Some factors to consider when determining whether an employee violated a prohibited act:

  • Did the employee know of the prohibition?
  • Was the prohibition was regularly enforced?
  • Is their fair reasoning behind the prohibition?
  • Was the performance of the prohibited act unreasonably dangerous?
  • Could it be understandably foreseeable by the employer that the prohibited act would occur and no precautions were taken?

Failure to follow safety rules does not always bar employees from claiming workers’ compensation. Having clear and concise policies, however, can help to improve the safety of employees, decrease the chance of work-related accidents and workers’ compensation claims and help keep workers’ compensation premiums reasonable.

About Associated Specialty Insurance Agency

At Associated Specialty Insurance Agency (ASIA), we specialize in Workers’ Compensation needs for a variety of businesses. Depending on the type and size of your business, we aim to foster a sense of safety and protection within your clients’ company with our industry specific underwriting expertise. For more information about coverage throughout our target states of New Jersey, Pennsylvania, New York, Connecticut, Delaware, Maryland, Virginia, North Carolina and Florida, contact us today at (866) 679-7457.

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