The workers’ compensation system provides financial support and medical care for employees who were injured or became ill because of job-related activities. Created in 1912, the Michigan workers’ compensation system minimizes the risk to employees and employers when a workplace injury occurs. In exchange for defined benefits and a no-fault administrative system, workers gave up the right to file personal injury lawsuits against their employers in civil court for work-related injuries.
While most workers file legitimate claims for benefits due to work-related injuries, not all claims are covered under the workers’ compensation system. Risk managers, human resource personnel, litigation adjusters, and other claims professionals are tasked with carefully evaluating claims for workers’ compensation benefits. There are many reasons a claim for workers’ compensation benefits can rightfully be denied. Here, we identify some of the most common reasons for a claim denial.
MacArthur, MacArthur & Associates, PLLC, is a workers’ compensation defense law firm in Michigan. We provide legal advice, guidance, and representation to insurance companies, high-deductible insureds, and self-insured companies across a broad range of industries. Established in 1976, we have worked with many of our clients for decades and are proud to consider ourselves partners in their success.
The Michigan workers’ compensation system is a complicated regulatory framework that provides comprehensive benefits for employees who were injured on the job. To receive benefits, injured workers must prove their injury was work-related and provide the necessary documentation to support their claim. Here are some of the most common reasons a claim for workers’ compensation benefits is denied.
Workers’ compensation benefits only cover injuries that occurred on the job. To be eligible, an injured employee must prove the injury occurred while they were performing job duties or as a direct result of the work environment. A claim should be denied if the injury occurred while the worker was not performing work-related duties.
Only employees are eligible for workers’ compensation benefits. If the worker was an independent contractor, they do not qualify for workers’ compensation benefits.
A worker’s status as an independent contractor for purposes of a workers’ compensation claim is not always the same as for tax purposes or other inquiries. We recommend consulting with experienced legal counsel before denying a claim because the worker was not an employee.
To receive workers’ compensation benefits, the injured worker must report the injury to their employer in a timely manner and file the claim within the deadlines established by Michigan law. An employee who misses filing deadlines may not be entitled to workers’ compensation benefits.
An injured worker must promptly report their injury to their employer. If the employer is prejudiced by delinquent reporting, an employer may deny the claim for benefits.
An employer may deny a claim for benefits if the employee fails to provide sufficient evidence to prove the injury was work-related.
A claim for benefits may be denied if the worker’s injuries resulted from a pre-existing condition and not a job-related accident.
An employer can deny a claim for benefits if the employee is injured by reason of his intentional and wilful misconduct.
Claims for workers’ compensation benefits should be denied if the employee provided false information about the injury or the circumstances under which it occurred.
Risk managers, human resource personnel, litigation adjusters, and claims professionals should approve claims that meet all state and internal guidelines. However, if the employee fails to meet the required conditions or the claim is not legitimately work-related, the claim for benefits should not be approved.
When a claim for benefits is approved, the claims professional should complete Form WC-701 “Notice of Compensation Payments, which is used to report to the Workers’ Disability Compensation Agency the employee’s weekly workers’ compensation benefits. The Form should identify the date of injury, the body part(s) injured, the nature of the injury, and the wage loss calculation. A completed Form WC-701 is proof the claim was properly made and approved for benefit payments.
If an employer denies a claim for benefits, they must provide the claimant with a Form WC-107 “Notice of Dispute.” The Form WC-107 should explain why the claim was denied, such as late reporting, a pre-existing medical condition, employee misconduct, reasons set forth in the Independent Medical Evaluation report, or some other reason. We recommend speaking to an experienced Michigan workers’ compensation defense lawyer when a claim for workers’ comp benefits is disputed.
MacArthur, MacArthur & Associates, PLLC, is one of Michigan’s preeminent workers’ compensation defense law firms and has earned a Martindale-Hubbell Preeminent AV rating, a peer-reviewed rating designating the highest level of professional excellence. We are pleased to offer thorough investigations, thoughtful legal analyses, definite economic assessments, and candid advice in Michigan workers’ compensation matters.
Our lawyers work with risk managers, claims professionals, human resource managers, and litigation adjusters who work for self-insured employers, high-deductible policyholders, insurance companies, and third-party administrators. We approach each claim with a disciplined, practical approach aimed at reaching the best possible resolution for our client.
To learn more, contact MacArthur, MacArthur & Associates today to discuss your workers’ compensation defense needs.
This article has been prepared by MacArthur, MacArthur & Associates, PLLC, for instructional purposes only, free of charge, not for reproduction, sale, or distribution beyond the intended recipient.
