Worker’s compensation provides coverage for medical bills and lost wages if you ever injure yourself on the job. Often, Virginia worker’s compensation get denied for many different reasons. (If you’re looking for more information about the specific types of benefits you may be entitled to, check out our post about the types of workers’ compensation benefits here.)
A workplace injury is compensable under the Virginia Worker’s Compensation Act if it “arises out of employment” and occurs “in the course of employment.” These are two common legal phrases used to characterize the injury as one that falls within the limits set by the Act.
Essentially, the injury must:
- happen during work hours,
- happen at the physical location of your job,
- happen while you’re doing something related to your job responsibilities,
- be caused by something related to your job.
Based on these requirements, you may think it’s a no-brainer that your claim will be approved. However, eligibility can be a bit more nuanced depending on the circumstances.
When faced with a denial by your employer or their insurance company, there are generally a few factors at play.
The type and timing of your injury
In most cases, the type of injury does not impact the success of your claim. However, it is worth noting that the Virginia Worker’s Compensation Act does not generally provide compensation for mental health-related injuries. There are exceptions to this, including mental injuries from otherwise compensable physical injuries and PTSD of law enforcement and firefighters. If you received a denial for your claim for depression or anxiety, it is likely because that type of injury is only compensable under the Act in limited circumstances.
More commonly, the timing of the injury could lead to a denial of your claim if your injury happened while doing something a bit more loosely related to your job. This could look like visiting a client, attending a conference, or stopping at a restaurant on your lunch break. These may be things you would never have been doing if you weren’t on the clock. But there are some specific rules that may come into play when your claim was denied.
In Virginia, accidents that take place during your commute to and from home do not receive worker’s compensation coverage. There are certain exceptions such as driving a company vehicle, traveling on a business trip, or driving between job sites.
Similarly, accidents that take place during your lunch break generally do not receive coverage unless your job responsibilities include lunch. Things like picking up catering for a meeting or having a lunch meeting with a client would be the types of activities that could receive coverage.
There is some evident gray area within which compensability is a highly fact-specific determination. Your claim may fall into one of these exceptions for commutes or breaks. If so, hiring a worker’s compensation attorney who understands Virginia worker’s compensation law can help appeal a wrongful denial. At Osterbind Law, we have handled a wide variety of worker’s compensation cases. We will be able to help you navigate all the rules and exceptions that apply to your case.
The notice requirement and deadlines
There are some hard and fast deadlines set forth by the Virginia Worker’s Compensation Commission for making a claim. If your claim was denied, it may be that you did not make it within the permitted time frame. According to the Commission:
You should report the work-related injury or illness to your employer as soon as possible. Do this no later than 30 days after the accident, or within 30 days of the work-related inury. Your employer should file a report of the accident or disease with the Commission within 10 days. Failure to report your injury or illness to your employer within 30 days could result in your claim being denied. See Va. Code § 65.2-600 for more information.
Additionally, the Commission requires that:
A worker must file a claim for workers’ compensation benefits within two years of the date of the accident. For most occupational diseases, you must file a claim within two years of the date you were told the disease was caused by your work and within five years of the date you were last exposed at work.
If you don’t give your employer notice or make a claim within the time frame, you will not likely receive compensation. If you hire Osterbind Law, we are aware of important deadlines to protect your right to make a claim.
Unapproved medical care or no medical care at all
The medical care that you obtain for your injuries is another factor that can sometimes lead to a denial. Va. Code § 65.2-603 requires that your employer provide you with a list of at least three physicians who can treat your injuries to choose from. You generally must see one of the listed physicians unless you have a medical emergency. If your employer does not provide a list of approved physicians within a reasonable amount of time for you to get the care you need, you are free to pursue treatment with the doctor you deem appropriate without hurting your claim.
Not seeing a doctor for your injuries or refusing the course of treatment recommended by a doctor can also constitute grounds for denial of your claim. It is essentially impossible to prove that you should receive a lifetime medical award if you don’t expend any time or money to get better. As we often tell our clients, there is no difference between what is in the best interest of your health and the best interest of your case. To the extent that a provider’s recommended course of treatment seems unreasonable or harmful, consider a second opinion from one of the other listed providers.
Pre-existing conditions
A worker’s compensation claim may be denied if you have claimed an injury that pre-existed your workplace accident. The exception to this rule is a pre-existing condition that worsened by a workplace accident. If you have a pre-existing condition that is aggravated by a workplace accident, your medical award and lost wage award will be limited to the expenses and time off post-aggravating injury. This will not cover the full duration of the condition prior to your workplace injury.
Making a worker’s comp claim after leaving a job
There may be several reasons to leave a job after a workplace injury. Perhaps you feel that the environment had unsafe conditions, or that you did not receive fair treatment after you reported your injury. You may even leave your job for unrelated reasons and discover an occupational disease at a later date.
Leaving a job for any reason does not prevent you from claiming worker’s compensation benefits; however, it is common for claims to be denied if you do. This occurs frequently because it is more challenging to show that your injury happed because of your job rather than more recent jobs or activities. This scenario is much more common when you are claiming an occupational disease rather than a one-time accident. Giving notice to your employer and getting medical treatment as soon as possible is the most important step to prevent your claim from being denied because you left your job. Those two steps help reinforce the causal link between your job and your injury.
Employee conduct
In a worker’s compensation claim, the standard for employee conduct is relatively low. You can still claim an injury if your negligence contributed to the accident. However, injuries resulting from intentional conduct, such as fighting or purposely inflicting injury on yourself, will not be compensable. Additionally, the presence of intoxicating substances in your system at the time of a workplace accident will almost always lead to a denial of your claim, unless you can clearly show that the intoxication in no way caused the accident.
What are my next steps?
The exact reason for the denial of your claim is directly in your denial letter. Once your employer or their insurance company denies your claim, you should proceed to make your claim with the Commission. Making a claim and any subsequent appeals entails a number of procedural requirements that may culminate in a mediation or a hearing before the Deputy Commissioner. (For more information about the potential advantages of resolving your claim through mediation read our post on worker’s compensation mediations here.)
If you need an attorney to walk you through the process of making a claim or appealing a denied workers’ compensation claim, Osterbind Law is ready and willing to help. We offer free strategy sessions for all potential workers’ compensation cases so that you will know how to proceed, no matter what route you ultimately choose to take. Contact us today to set up your free strategy session.
