Human Resources News & Insights

Worker delayed injury report: Can he still collect bennies?

Ever get suspicious when an employee reports an injury long after it supposedly occurred?

Well, the courts do. And that’s good news for employers looking to keep insurance premiums down.

That exact situation caused a court in Illinois to deny a claim for workers’ comp benefits.

What happened

A man claimed he was injured three different times (on three separate occasions) at work. However, he reported the injuries 15 weeks after the first alleged incident, seven weeks after the second and a week after the third.

Two other problems:

  • Throughout those 15 weeks the worker saw his primary care doctor and chiropractor several times — and never mentioned anything about a work injury, and
  • His manager said he couldn’t link his medical condition to a specific work incident when he finally did report the injury.

Case closed: The man’s request for workers’ comp benefits was denied.

Have you every come across a situation like this? Tell us about it in the Comments Box below.

Cite: Hosteny v. IL Workers’ Compensation Commission

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  • James C. Edge

    Usually, when an employee does not report an workplace injury, he or she is on drugs. They know the first thing the medical center is going to do is a drug screen. It was mandatory when I was working. I was the Safety Director and I made sure that a drug screen was completed. What they don’t realize is that even if it is positive, we still have to pay the bill and in a lot of cases we can’t just fire them either. It’s a suff situation sometimes for the employer. Other reasons is that the employee did not get that ankle hurt at work but at home on the weekend playing basket ball or something not related to work.

    V/R,

    James C. Edge

  • DL

    I think it depends on the type of work/business it is. In certain types of jobs I think there is a chance the employees will lie. On the other hand, trying to lift a large box in the office a few years back I sprained my wrist. I tried to deal with the pain myself for over a week before I finally went to the doctor. Waiting a week didn’t mean I was lying….it just meant I was trying to avoid taking time off to go to the doctor.

  • Maria

    We had that exact situation here. A shop employee, who we realized could not be trusted because of other issues, came to me after he found out he was being laid-off and said he had jammed his elbow 4 months prior. When we had brought him on he had told his supervisor he hurt his elbow at a previous place of employment. When all was said and done it ended up costing us a year’s worth of paid work comp time and surgeries and therapy. We gave our work comp company all types of testimonials from other employees showing that the employee was lying but we still ended up paying the cost of all of it. This same employee also tried to get unemployment while he was getting work comp pay. And he is now going to trial for fraud with regards to forging vehicle title documents. It seems that we should be able to turn around and sue him for all the money we have paid him.

  • Tom

    Maria,

    You probably can sue him, but whether you will ever see a dime is problematic and you will still have the time and legal expense as well because I doubt any lawyer would take the case on contingency. The laws are stacked in favor of the employee over the employer and we just have to accept that fact and do the best we can.

  • Judy Buckley

    I’ve only had one person claim worker’s comp that I thought was lying. She had 2 prior cases (for one wrist) and only reluctantly went to the doc, didn’t follow through with all the PT, etc. Then we had an RIF and she came in early the next day and left a note from a doc claiming disability for a month, followed by changing that to a worker’s comp claim with a lot of added body parts that were never previously reported. We are disputing this and, hopefully, because we were asked for a copy of her personnel file, all the info in there showing her money difficulties (ie pay advances, etc.) will be admissible. When people get their backs against the wall financially, they can go into “survival cheating” mode. They can rationalize and compartmentalize (ie their ideas of right and wrong seem to be kept separate from the need for money) – it’s a shame and a waste of our staff time to produce all this documentation. All I can say is I hope for a fair outcome.

  • Brenda

    Worker’s comp is totally geared towards the employee (which it should for those that are honestly hurt), but it’s unfair for employers who are stuck with a claim that isn’t legit. We have a case just like this currently. Why is it that workers comp sends you posters telling you to report frauds and then when you actually do, they don’t do anything about it!!! So frustrating. I am totally for people getting help when they deserve it, but those that abuse the system make it harder for everyone else. And the system is set up to be so easily taken advantage of. The sad part is that once someone figures out how easy it is, they usually work it to their full advantage, not everyone, but I can see how enticing it could be.

  • Andrea Rudman

    We had an incident where 6 weeks after a RIF due to the end of a job, and employee claimed a comp injury. The nature of the injury he claimed would have been obvious to everyone on the job site since he would not have been able to work. The date of injury was disputed since we had proof he didn’t work that day at all. The people listed as witness provided certified depositions that they never saw him injure himself. We provided proof that he continued to work for 3 weeks after this disabling injury. Good old Washington State said WE were wrong and provided him medical care, retraining (which didn’t take), and last year pensioned him off, so he will get a lifetime disability pension. When we got that notice, we sent all our information again (10 years after the fact) to protest this. We were told that it was too late to go back to try and prove fraud. No wonder the state is $8 BILLION in the hole.

  • Essie

    James: I bet you’re right. I stupidly sliced open my finger on a FED EX box trying to juggle too many things in the rain at the end of the work day. I was called by HR while getting three stitches in the Emergency Room and told not to return to work until I had taken my drug (urine) test.

  • http://www.janitronicsinc.com Chris

    In this great State of New York, it happens all the time! The WCB almost always accepts prima facia medical evidence to declare the injury or condition work related. I am stuck with the bill by doctors looking for guaranteed payment, employees and former employees utilizing the WC system as a health plan and retirement plan, and let’s not forget the lawyers! The lawyers make out better than anyone as employers and insurance companies are quick to settle “nuisance” claims. I currently have two former employees who voluntarily resigned for non-work related health reasons and two that failed post accident drug tests. NY does not disallow benefits for drug abusers.

  • Patrick

    Interesting reading because you would think that the obvious would be obvious. Here’s my story. EE came to work saying his back hurt, already my radar is on. I spoke to him directly and he said he didn’t know how he hurt it, he just woke up in the middle of the night in pain. I asked if it happened at work, No was the answer. We joked about how our bodies are no longer covered under warranty (past 50) and he said he would be fine. I document all of this. One week later I ask EE how’s his back and he says it still hurts a little, he sleeps on the floor to help and takes Advil. I ask again if it happened at work and now he says that he may have pulled a muscle when loading a die but he wasn’t sure when it happened and stated it was getting better and that he was OK. I document the conversation and move on. Now 29 days after the first day I spoke to him an accident report was under my door. It spelled out the exact date, time of injury and goes into detail of how the injury occurred. I called this into our carrier, gave them the history and stated that I questioned the validity of the claim. The carrier accepted the claim then I sent a letter to corporate and the carrier saying that the EE failed to provide an accident report within 24 hours and this allowed him to go 29 days without a drug screen. Further the claim failed to meet the qualifying criteria of knowing the accident occurred at work which the EE has denied and when asked he could not identify how it happened. The company CFO chewed me out for questioning the Carrier and the claim was entered. The company ended up paying for all of his back surgeries (fused discs) and then they paid over $100K in a clincher agreement when he could not return to work. The CFO lost her job within the year but I am not sure if the two issues were related.

  • Lynn

    Chris,

    My company too, is a victim of New York State. We had an employee who claimed he hurt his wrist at work with an exacto knife, did not place the claim until a week later, and it all happened supposedly at work. He was a second shift person, and no one else saw the accident or the bleeding that he supposedly said happened. All evidence implies that this accident happened at home, but yet, NYS gives no credit to the employer. The case has gone on for over 2 years, and he’s been awarded for $15,000 due to a schedule loss of his wrist. I’m tired of employers having no rights in this state! We have to fight 10 times as hard to win a claim than the employee. And don’t even get me started on the unemployment system! All I see is tons of state money being wasted on these cases that shouldn’t have ever gone this far. I think NYS could greatly help its debt problem by not allowing this garbage to exist.

  • JK

    Everyone who posted has valid concerns as fraud and abuse is widespread in Workers Compensation. However, I do not believe any employer would want to risk the alternative, which is civil litigation. Depending on what state you are in, you could end up with a very large cost by having a small percent of contributory negligence.

    The real problem I see in WC stems from medical providers who do not care. It’s easier and safer for them to give cause and relation to a condition that had one of their employees brought claim against them with the same circumstances, they’d fight it vigorously. Some providers even establish their practices to specifically treat WC as there is considerably less oversight, (of course these providers tend to be the less competent). A recent audit by “Best Doctors” found 61% of files had incorrect treatment, 38% had inappropriate surgery and 12% had misinterpretation of diagnostics. Where is the real problem?

  • JenLee

    We are in litigation with an employee that did not report her worker injury until it had caused irreversible physical damage. The employee worked in pain for years because her culture believes you will be terminated if you complain. While I feel compasion toward her I don’t feel we should be required to pay more than a years salary. If she had followed company policy she would have been as good a new by now. This was a repetative motion injury.

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