Injury Claims Ohio Workers’ Compensation Will Typically Deny – And Why You Should File A Claim Anyway

workers compensation claims denied July 20, 2021

Workers compensation can be complicated. The program is designed to provide financial compensation for both medical care and wage loss after a worker has sustained an injury in the course of their employment or as a result of a risk or hazard directly related to their employment. In many instances, the injured party simply files a claim with the Bureau of Workers Comp (BWC), the claim moves through the approval process and the worker can begin collecting benefits. Unfortunately, not every case is so simple or straightforward.

Claims can be denied for many reasons, often because a form was filled out incorrectly, not enough information was provided, a disparity is found between the accident report and the documented injuries, a claimant did not seek medical treatment, or missed filing deadlines. Some of the most common denials cited happen when injuries fall outside the course or scope of employment.

Some of the most common denials of claims stem from the following circumstances:

Injuries sustained en route to work:

Ohio Bureau of Workers Compensation typically does not cover injuries sustained during a commute to or from work. This is known as the “coming and going” rule, which states that commuting does not fall within the scope of the employment relationship. There are, however, some exceptions to this rule, which means it is important to talk to an attorney to find out if your injury falls within one of them.
When and why you should apply anyway: Some judgments in commute-based disputes have sided in the favor of workers. For example, in the case of Ruckman v. Cubby Drilling, an employee injured in a carpool commuting to a remote worksite was deemed eligible for workers compensation. In Durbin v. BWC, an employee who was injured while answering a page from an employer while driving was entitled to workers compensation benefits. Your case may contain extenuating circumstances that require a more nuanced approach. Always talk to an attorney before declining to apply for a claim or make an appeal.

Pre-existing injuries:

A pre-existing condition is a medical condition that an employee had prior to his or her work-related injury. Claims involving pre-existing conditions are often denied. This is because the injury is not considered to have occurred within the scope of employment, even when the pre-existing condition creates problems with a person’s ability to do their work.
When and why you should apply anyway: If you have a pre-existing condition that is affecting the outcome or care of an injury allowed under workers compensation, or if a pre-existing condition is being substantially aggravated or worsened due to work-related injury, your claim may be approved. It’s important to consult with your doctor about how and why your injury has been aggravated before you proceed. You may also want to work with an attorney to ensure your claim is filed or appealed correctly with the right information.

Injuries sustained during optional recreational activities with coworkers:

Injuries that are a result of voluntary activities outside of work like a company-sponsored softball league are usually not considered within the course of employment as they are optional and often occur off company premises. Companies may even ask employees to sign a waiver in order to participate. However, even these cases can be compensable in some instances.
When and why you should apply anyway: Cases like Pilar v. BWC and Kohlmayer v. Keller highlight that injuries sustained during work-related recreational activities can sometimes be compensable. In these cases, injuries often occurred on company grounds or during the course of the workday. If you’ve been injured during a recreational work activity, it’s important to relay all the facts of your case to your attorney so your claim will have the best chance for approval.

Injuries resulting from horseplay or fighting at work:

Engaging in horseplay or physical fights at work is almost universally frowned upon by employers. It takes away from time on task and has a high risk for injury. On-the-job injuries that result from horseplay are therefore rarely considered within the course of employment and are typically denied by the BWC.
When and why you should apply anyway: If you have been assaulted at work, your claim may be approved. Additionally, cases like East Ohio Gas Co., V. Coe state that a friendly scuffle between coworkers may be compensable, provided the activity didn’t cause the participants to “engage in some actions entirely foreign to his employment.” If you’ve been injured at work as a result of horseplay, talk to your workers compensation attorney to find out what next steps need to be taken to make sure your case is handled correctly.

Injuries that occur while under the influence of drugs or alcohol:

When an employee is injured on the job after consuming alcohol, it can be a tough call to determine if the case is actually compensable. Most of the time the BWC will reject cases that involve intoxication on the job, particularly when it is clear that the amount of drugs or alcohol in a worker’s system were such that he or she could no longer engage in their work duties.
When and why you should apply anyway: As always, some exceptions exist so it is important to relay all the facts to the best of your ability during the claims process and to an attorney before you file. In the case of Chester Scaffolding Inc. v. Hanley, an employee consumed alcohol during lunch, but was able to resume his duties afterward. When he later died due to injuries resulting from an on-the-job fall, the courts rule that the evidence did not suggest his death was related to intoxication. Unless an employee’s intoxication incapacitates him or her from job duties, this rule may not be used to deny a claim. 

Stress- or mental health-related injuries:

Ohio does not recognize mental injury or psychological disease due to work-related stress as a workers comp injury.
When and why you should apply anyway: However, if your mental injury or psychological condition is a direct result of a physical workplace injury that you experienced, you may be entitled to compensation. Additionally, some claims that result from another coworker’s death claim (Bailey v. Republic Steel), or another traumatic event that occurred on the job (McCrone v. Bank One Corp.) may be approved.

Bottom Line:

If you’ve been injured at work, always apply for workers compensation. If you’re not sure, talk to an attorney. A workers compensation lawyer can advise you about your case and what next steps you will need to take.

Contact Lowe Scott Fisher Co., LPA today to get a free consultation with a workers compensation attorney today. We can help determine how best to proceed with your case and make sure you get the compensation to which you may be entitled.

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