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Challenging Injury Claims

Do you have a workplace claim you can’t verify? Suspect the injury is non-work related? Facing challenges getting the employee back to work and don’t know what to do next? We all face challenging claims and sometimes need help. Below is insight and action you can take to help manage challenging claims. You are not alone; Dunk is here to help you find a successful way forward.

First off, in order to help you decide whether the claim was warranted, you need to consider if there is both proof of the incident and compatibility of the diagnosis to the incident or disablement history. During your investigation consider the following:

  • Was the incident occupational or non-occupational? (For example, did the worker come into work on Monday complaining of a sore back, but you discover that they helped move a friend on the weekend?)

  • Is there a lack of compatibility of injury to the incident? (For example, the worker is claiming they hurt their knee just walking down the hall)

  • Were there witness(es) to the incident?

  • Was there a delay in reporting the incident and/or seeking medical treatment?

  • Was medical treatment sought after the incident?

  • Does the worker have a pre-existing non-work-related injury?

  • Timing of the claim (For example summer off, before the Christmas holidays, was previously denied requested time off.

For cases where the worker is declining modified duties, do not be afraid to discuss your concerns with the Compensation Board Case Manager. Submit the written offer of modified duties to the Case Manager so they can review the offer to ensure that the offer is suitable, given the worker’s restrictions. Remember, the compensation board has access to all of the medical documentation and has a better understanding of the worker’s capabilities. Keep the compensation board well informed as this will be beneficial when objecting to any lost time if the worker declines the modified duties.

Follow up with an objection letter that states the loss of earnings should not be allowed for the claim as you offered suitable modified work to the worker. Within this letter, question the severity of the injury as in order for a worker to remain off work they must be totally disabled and there is the inability to return to suitable modified work. Argue that you do not feel that the injury in question meets that requirement.

However, remember when objecting to the claim focus on the issues and leave out your emotions. Be clear as to why you are objecting and state the facts. Remember that for the compensation board to make an informed decision, it is vital that you present all of the appropriate documentation.

Have any questions about a claim? Dunk & Associates offers claims management services.

Contact us today for more information!

Want to learn more? Join us for this month’s webinar on June 21, 2023 by clicking here.


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