When conducting your initial investigation, it can be difficult to determine which facts favor either an admission of liability, or a denial. In this article, FJL weighs some common scenarios that present themselves during the investigation phase and what it may mean for your primary liability determination:
- What if medical records provide a different history for the employee’s alleged injury?
This is a pretty common scenario and can be a basis for a good faith denial of primary liability. This is part of the reason why obtaining the initial medical records is important. If there are different accounts for the alleged injury, those differences can call into question the credibility of an employee, and ultimately be a reason to deny a claim.
2. What is the physician’s diagnosis is inconsistent with the treatment?
This can be a basis to deny medical benefits, but not necessarily a basis to deny the claim. For example, if the doctor is prescribing inappropriate or excessive treatment, the employer and insurer may have a reason to deny that treatment. However, it may not be disputed that an injury occurred, and other benefits still may be owed.
On the other hand, if it appears medical documentation has been altered or is fraudulent, that may be a basis to deny the whole claim, depending on the specific facts. This is very rare.
3. What is the employee did not report an injury? Or delayed reporting the injury?
This can be a basis to deny the claim. Under Minn. Stat. § 176.141, unless notice is given within 180 days, there is a good faith basis for denial except if the employee is unable to give notice due to mental or physical incapacity. Also, under Minn. Stat. § 176.141, if the injury is not reported within 30 days and the employer is able to show prejudice due to the employee’s failure to notify the employer and insurer, benefits can be denied to the extent that the employer and insurer can show prejudice. Lastly, unless the employer and insurer have actual knowledge or gets notice within 14 days after the occurrence of the injury, no compensation shall be due until the notice is given or knowledge is obtained.
Notice defenses can be difficult for employers and insurers to prevail on. More often than not, an employee will allege that he or she did speak to someone about the injury, and alleges he or she reported what happened. It may be important in these circumstances to speak to colleagues or supervisors to get the story straight.
4. What if the employee is not willing to talk or conduct a recorded interview?
Although this can be frustrating, this (in and of itself) is not a basis to deny the claim. However, if other initial investigation results in more red flags, this factor can be used to help strengthen a denial. From time to time, a claims professional will encounter a difficult claimant who will refuse to cooperate. When that happens, focus efforts to other parts of the initial investigation.
5. What if an employee reports an injury just before or right after leaving a job?
This is not a standalone basis to deny a claim, but it is still worth noting. This can go towards motivation, and ultimately can impact the credibility of an employee’s claim. As part of the initial investigation, a conversation should take place with the employer, in part, to discuss a potential notice defense or refusal of suitable employment.
6. What if an injury is not witnessed?
This would not be a good faith denial, by itself. Injuries can often be sustained without being witnessed. This is common. The best approach here would be to look into the medical records and determine what was reported to the doctor. Check with the employer to see if the injury is plausible. In most situations, the claim should be admitted, but there can be exceptions.
Even after conducting a full and good faith investigation, it still be can difficult to determine whether or not to accept or deny a claim. There is a significant amount of nuance within these examples, and a single fact may push the analysis of your particular claim one way or another. As always: please reach out to any of the attorneys at FJL for guidance or recommendations on your specific claim!
Original article from FJL Spring 2025 Seminar: Lisa Truitt (612) 746-3471 | ltruitt@fitchjohnson.com Dan Skarie (612) 746-6631 | dskarie@fitchjohnson.com