Exterior of the Office Building of Sagaser, Watkins & Wieland PC

When workers claim benefits for injuries from outside work

On Behalf of | Aug 17, 2021 | Worker's Compensation

As a California employer, you probably do everything you can think of to help keep your employees safe. You provide them with safety equipment and proper training. You post all of the required information for your industry and carry workers’ compensation insurance in case someone gets hurt on the job despite your best efforts.

For the most part, the employees who file a workers’ compensation claim will have an injury that they obviously suffered because of their job responsibilities. You will probably work with them to help them get benefits and then back on the job. However, on rare occasions, people with medical conditions unrelated to their work can try to manipulate the workers’ compensation system.

Why would workers with health insurance try to claim workers’ comp instead?

If you offer health insurance benefits for your workers, you already know that they have good coverage for any injury or illness they develop. Employees with their own health coverage don’t need workers’ compensation because their insurance policy will cover their care.

However, most health insurance policies have co-pays, deductibles and coinsurance that leave people with thousands of dollars of financial responsibility. Filing a claim through workers’ compensation means that that employees won’t have any personal costs to cover for their health care. This coverage offered pays 100% of their necessary medical care.

A workers’ compensation claim could also mean that the worker can receive disability benefits. They can receive a portion of their wages while they recover instead of needing to use their paid time off during their convalescence.

What can you do about a claim that you question?

California protects the interests of injured workers and employers with its balanced workers’ compensation system. The state certifies qualified medical examiners (QME) to help verify the origins of medical conditions and the necessity of care.

You can ask that a three-person QME panel review the case if you suspect that the injury is not directly related to someone’s employment. The state goes to great lengths to ensure neutrality when assigning a QME to a case. In theory, a QME could help show that an injury was not related to work and could reduce your company’s liability.

Knowing the options available to employers dealing with workers’ compensation claims will make it easier for you to respond to a claim you find questionable.