Rejected and Denied Claims

Iowa work comp cases are handled through an adversary system of justice. The theory is that the truth will be revealed through the process of the employer and employee each arguing their side of the dispute before a neutral work comp judge.

Therefore, a decision by an employer or insurance company to reject or deny a work comp claim is not necessarily the end of the story. Some denials are certainly valid, and not every workers’ compensation claim can be won.

However, in other situations where an injured worker’s claim is rejected or denied it turns out that the worker is actually entitled to workers’ compensation benefits.

Our law firm regularly analyzes the cases of injured workers that have been rejected or denied by work comp insurance companies. In many of these cases we are able to obtain money and medical care for the injured workers. Sometimes we are able to get benefits for our clients fairly quickly. In other situations we have to pursue litigation to get our clients the payments and care they are entitled to receive.

Every work comp case is different and there are countless reasons that an employer or insurance company might reject or deny a work comp claim. Here are some of the more common areas of dispute.

Aggravations of Pre-Existing Conditions.

Many workers have pre-existing problems from a prior injury or a degenerative condition. Under Iowa work comp law if work activities materially and permanently aggravate or light up a pre-existing condition, then the worker is entitled to receive money and medical care for the aggravated condition.

In many cases involving aggravations of pre-existing conditions there is disagreement on whether work materially aggravated the condition, or whether the condition was just naturally worsening on its own. In order for an injured worker to receive compensation for the aggravation of a pre-existing condition, he will frequently need supporting expert testimony from a physician, and the dispute will have to be litigated.

In many aggravation cases there is no single incident that causes the injury such as the worker falling or being struck by a piece of machinery. Rather, the aggravation is caused by the cumulative trauma of the job over a long period of time. Iowa law does recognize and provide for compensation for cumulative trauma work injuries. Proving a cumulative trauma injury will again often require obtaining and presenting expert opinions at trial.

Disagreements Over Whether The Injury Actually Occurred At Work.

In some cases the employer will disagree that the worker was injured on the job. For example, the employer may believe that the worker is lying, and that he was actually injured while he was off work. This type of factual dispute tends to require litigation in order to resolve.

Is The Injured Worker an Employee of the Employer?

A fundamental requirement for all workers’ compensation claims is that there has to be an employer-employee relationship at the time of the injury. Some employers require their workers to sign written agreements that they are not an employee of the employer. These written agreements can be a factor in deciding whether there is employer-employee relationship, but they are not conclusive.

Disputes about whether there is an employer-employee relationship most frequently come up in the trucking and construction industries. Five factors are examined to determine whether the injured worker is an employee of the employer. These five factors are whether the alleged employer has:

  1. The right to select which workers will do the job.

  2. Responsibility for the payment of wages.

  3. The right to discharge or terminate the worker.

  4. The right to control the details of the work.

  5. The authority to be in charge of the work.

Over the years there have been hundreds of decisions by the Workers’ Compensation Judges and the Iowa Courts that have helped refine and provide precedent for how these factors should be interpreted. Each case is very different and has to be analyzed carefully to determine whether the injured worker qualifies as an employee who is entitled to work comp benefits.

Did The Injury Arise Out of Employment?

The phrase “arising out of employment” is very short, but has also resulted in extensive litigation. The general rule is that an employee must be able to establish that there is a connection between the injury and some aspect of the employment.

Did The Injury Arise In The Course of Employment?

In order to prove that the injury arose “in the course of employment” the employee generally has to show that he was injured while furthering the employer’s business or doing a task that is common to his job. However, it is not necessary for the employee to show that he was performing actual work activity at the moment he was injured.

The types of disputes that come up over whether the injury was in the course of employment are issues such as:

  1. Generally during an employee’s commute to and from work they are not covered by workers’ compensation insurance. In contrast, once the employee is on or about the premises of the employer there generally is coverage.

  2. The specifics of how an employee was injured during a meal or a break are critical to determining whether or not there is coverage.

  3. There are an amazing number of cases involving injuries while employees were going to the restroom. Again, the specific details surrounding the injury make a huge difference in determining whether or not an injury during a restroom break is covered by workers’ compensation.

  4. Employees that are injured while voluntarily engaged in horseplay during work frequently are not entitled to receive work comp benefits. By contrast, a worker who was a non-participant in the horseplay, but who was injured, will generally be allowed to receive workers’ compensation benefits.

  5. Many workers have to travel as part of their job. Injuries during such travel are generally covered by work comp. However, if a worker has deviated from his work travel to pursue a personal errand then there is the possibility that there will not be coverage for an injury that occurs during the deviation. These cases involving deviations from work travel are some of the most complex cases that come up in the Iowa workers’ compensation system. The specific nature and extent of the deviations becomes critical in determining whether or not the injured worker will receive work comp benefits.
Did The Injured Worker Provide Notice Within 90 Days of The Injury?

Iowa law requires that an employee gives his employer notice of a work injury within 90 days of the occurrence of the injury. If the worker fails to provide this notice, then the worker is not entitled to receive work comp benefits.

The best practice for a worker who is injured on the job is to give very specific notice to his supervisor that he has sustained an injury and that the injury was caused by work.

However, Iowa law provides that it is sufficient if the employer has “constructive notice” of the injury. The details of the constructive notice are critical, but in some cases the claim of a worker who has not given clear notice of his injury can be saved.

Iowa law also has several exceptions that can extend the 90 day notice period.

Was The Injury Caused By Intoxication?

If a worker is intoxicated by drugs or alcohol and the intoxication was a substantial factor in causing the work injury, then the injured employee is not entitled to receive workers’ compensation benefits.

In contrast, an injured worker who was impaired by medication prescribed by a doctor may be entitled to receive work comp benefits.

Additionally, a worker whose job duties involve drinking may also be entitled to receive workers’ compensation benefits even though they were intoxicated at the time of their injuries.

Conclusion.

As mentioned above, this section just outlines some of the most common issues that lead to the denial or rejection of workers’ compensation claims. Every case is different, and our lawyers analyze the facts and relevant law of each case to determine whether we can obtain benefits for our clients.

If you believe you have been injured on the job, but your claim has been rejected or denied, you can call or email us to discuss your case. There is no charge or obligation involved in asking us to help determine whether you potentially have a valid work comp claim.