I may have contributed to my work injury. Can I still make a claim?
In theory, the workers’ compensation insurance system is supposed to provide compensation for a work-related injury or illness, regardless of the situation that caused it. One of the major components of the system is that a claimant does not have to prove fault. Instead, they just have to be an employee, and their injury has to have occurred “within the scope of employment,” which means in the course of job-related duties. This system differs from other forms of insurance, such as liability insurance, where the cause of the injury matters a great deal.
However, there are some exceptions to this rule. One of the biggest ones is that, in Florida, workers’ compensation claimants have to document the “major contributing cause” of their injury. If the major contributing cause was determined to be from an outside, non-work-related cause — meaning work circumstances accounted for 50% or less of the reason the injury happened — then the employee is ineligible to receive workers’ compensation.
There are also other rules and exceptions to being able to file for workers’ compensation when your own actions have contributed to your injury, which will be listed below. Know that you always have the option to work with an experienced work injury lawyer in Tampa, though. An attorney can help you make a workers’ compensation claim, appeal a claim, or file a separate claim against a non-employer third party.
What is a “major contributing cause”?
Workers’ compensation is intended to provide compensation for all employees who are injured in the course of their work duties. In exchange, the employer (whether an individual or a business) cannot be sued directly for the damage. Instead, a standardized system overseen by a state-run agency provides compensation for all qualifying injured workers.
The nice thing about this system is it’s not adversarial, meaning you typically don’t have to fight to retrieve your benefits. There’s no need to file a lawsuit against an employer or to prove it was somehow the employer’s fault your injuries occurred. Your injury could have been a total accident that no one could have predicted, and it will still be likely it is covered so long as it occurred within the scope of employment.
Note that scope of employment can involve any sort of situation where you are expected by your job to do something. That can mean working on a construction site, but it can also mean going to pick up a shipment on behalf of your boss in your own personal vehicle.
In Florida, claimants are required to list the “major contributing cause” of their accident, however. With many work injury claims, documenting the major contributing cause is straightforward and just a small procedural-type matter. But in other claims, especially ones where the cause is unclear, there may need to be a formal investigation to determine the actual causal factors.
When documenting major contributing causes, the goal is to prove that work-related circumstances contributed the majority (51% or more) of the cause to the accident. What this means is that your own circumstances could allow the workers’ compensation system to deny your claim.
There are several common scenarios where someone’s own actions or circumstances could violate the major contributing cause rule:
If someone had a pre-existing condition and the work injury is related to that condition, it’s possible for the workers’ compensation carrier to conclude that the pre-existing condition was the primary reason for the injury.
For example, if someone had a pre-existing back injury and they want to file a claim after they strain their back doing the heavy lifting at work, it’s possible that the workers’ compensation carrier will rule that the pre-existing condition was a bigger factor than the job-related duty.
Insurance carriers will often dig into the medical files of claimants to find pre-existing conditions and use them as a pretext to deny benefits. If you have been denied benefits, in part or in full, because of a pre-existing condition, you may wish to talk to a work injury lawyer to examine your options for appealing the denial.
Drug and Alcohol Use
As part of the process of filing a workers’ compensation claim, injured workers are expected to submit a sample for a drug test. If the sample shows that there are drugs in the worker’s system, then it will be presumed that the worker was intoxicated at the time of the accident, and their claim will be denied.
Other factors may be pulled in to confirm that it is likely that the employee was under the influence at the time of the accident. Co-workers may attest that the employee was stumbling and that they frequently smelled like alcohol, for example. A history of disciplinary actions for drug or alcohol-related incidents may also be used.
Reckless or Intentional Employee Behavior
On the whole, employees filing for workers’ compensation are presumed to have acted reasonably and in good faith when their accident occurred. Even if the employee may have not been paying close attention or if they violated a minor safety rule, these are often considered job-related risks that exist within the scope of employment.
There are exceptions, however, in extreme cases. If the employee was being completely careless or acting above and beyond the boundaries of unreasonable behavior, then they will often be considered to be the main contributing cause of their own injury. The employer may also allege that the employee intentionally hurt themselves or meant to cause harm to others when the injury occurred.
Keep in mind that it is easy for a workplace to casually blame an employee for their own injury, but it is hard to prove conclusively from a legal standpoint. Most often, the employee has to have a disciplinary record or a history of incidents, allowing the employer or insurance carrier to assert that another employee would not have been injured in the same scenario. If the employee was committing a felony at the time of the accident or was intentionally trying to get hurt or hurt someone else and this can be proven, then the claim will likely be denied.
Employees do have protection from certain allegations, though. For example, if they knowingly refused to use a safety device, then their claim is supposed to not be denied in full but merely reduced by 25% of its full value.
Third-Party Causal Factors
Another possibility for a claim being denied is that the injury or accident had a major contributing cause from an outside third party. For example, if a vehicle plows through a construction barrier and hits someone on the job site, the workplace or insurance carrier may try to say that the driver is the major contributing cause, not any working conditions.
In these situations, the injured worker can file a liability claim against this third party, but they may also still be eligible for workers’ compensation benefits if they can prove that the injury still occurred within the scope of employment.
What you can do when you are being accused of contributing to your own work injury
There are two main options for handling allegations that you contributed to your own work injury: appeal the denial of workers’ compensation benefits, and seek a claim against a third party for your damages. You can, in fact, do both, and it is often recommended by experienced Tampa work injury lawyers to do so when possible.
The cause of a work-related injury or illness is a complicated legal question. Working with an experienced attorney can allow you to investigate the full spectrum of circumstances and weigh all of your legal options. Many times, workers’ compensation boards will relent and provide benefits if the worker can disprove evidence that they were the major contributing cause to their own injury, for example. Other times, the worker can pursue a claim against a third party and successfully obtain compensation for their medical bills and other costs.
Overall, know that you have help from legal professionals available when you are suffering from a work injury. Don’t let insurers or employers try to take advantage of your unfamiliarity with all the complicated legal aspects of receiving benefits. Arm yourself with legal knowledge and representation from a firm with a proven history of winning compensation for its work injury clients.
Call Darrigo & Diaz today at (813) 774-3341, or contact us online, to schedule a free no-obligation case evaluation right over the phone to discuss your legal options today!