By: Stacy V. Pollock, Esq.
Workers’ compensation premiums can be an expensive and frustrating cost of doing business. Ohio’s Workers’ Compensation is a no-fault system, meaning employees nearly always are going to be eligible for benefits, even if they, themselves, are at fault for their injury. However, there is a small caveat to the law that few businesses understand, but could potentially save tens of thousands of dollars in unnecessary increased premiums if businesses recognize the issue and timely dispute the claim with the Bureau of Workers’ Compensation (“BWC”).
Claimants, meaning injured employees, are not permitted to recover benefits in limited circumstances. Some such situations include injuries incurred during a recreational activity (ie. using the company-owned weight room) if the employee signed a C-159 form, or for injuries from horseplay or intoxication, when the business has the appropriate procedures in place. Claimants are also not entitled to benefits for idiopathic injuries.
Idiopathic injuries are injuries that arise from circumstances unique to the individual. In the context of workers’ compensation, idiopathic refers to a claimant’s preexisting physical weakness or disease which contributes to the accident. For example, a diabetic claimant has neuropathy of the leg, unexplainably falls and sustains an injury from the fall. Unless the claimant is able to demonstrate that the diabetic neuropathy was not the reason for the fall (for example, there was water on the floor that caused her to slip), she should not be entitled to any workers’ compensation benefits.
One limitation to the idiopathic injury exception involves claimants with pre-existing conditions who are exposed to a heightened risk or hazard because of their employment. For example, an employee with a history of seizures works with a welding machine. While on-duty, he has a seizure and falls onto the machine, sustaining an injury from the machine. The welding machine is an added risk or hazard to the employment and therefore makes the injury eligible for workers’ compensation benefits even though the reason for the fall was the claimant’s seizure. However, if that same seizure-prone employee walks down the hall, has a seizure and hits his head on the floor, the floor is not an added risk or hazard to the employment. The individual could have had a seizure and hit his head on the floor anywhere outside of employment. As such, his injury from hitting the floor is not compensable.
Businesses should be mindful of this caveat in workers’ compensation laws. Many idiopathic injuries tend to involve serious injuries that drive up premiums once the claim is allowed. The BWC ordinarily will tentatively allow the claim without any investigation into the cause of the accident. Businesses are only permitted to contest whether or how an accident occurred prior to the BWC allowing the initial claim. Thus, it is critical that businesses assess each workplace injury immediately after the accident to determine whether such injury was actually received in the course of, and arises out of, the employment. If the accident is of some unexplained origin, businesses should explore with legal counsel the possibility of disputing the claim.
In sum, businesses need to take an active role in investigating and questioning workplace injuries, particularly when injuries occur to employees with a pre-existing condition. Businesses must contest those claims within fourteen days of the BWC’s tentative allowance of the claim. Failure to do so will forever bar the business from arguing that the medical conditions and wage loss claims on the claim should not be paid because the accident was caused by the claimant’s own medical condition.