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Conduct at Issue: Pennsylvania Workers’ Comp Denial Based On Behavior
If you’ve been injured at work, your employer’s insurer will likely try to deny you benefits. Learn more about some of the justifications workers’ comp insurers use to try to fight claims.

One Pennsylvania worker recently found out the hard way that violating a company policy can have real world consequences. In the case Dougherty v. Philadelphia Newspapers, a truck driver lost his workers’ comp wage replacement benefits when his employer discovered he had been carrying a loaded handgun in his work truck in violation of company policy.

Violating the company’s weapons policy was deemed “willful misconduct.” But, willful misconduct is just one of several excuses workers’ comp insurers often turn to in an attempt to avoid paying you in the wake a workplace injury.

Willful Misconduct as an Excuse to Deny Workers’ Comp Benefits

Workers’ compensation is meant to provide medical treatment for on-the-job injuries and occupational illnesses and to give workers financial support during the recovery process. Workers’ comp is paid regardless of fault, meaning that an employer’s negligence does not have to have caused the injury in order for the worker to recover benefits.

Yet, workers’ compensation is ultimately paid by an insurer, and insurance companies typically seek to avoid paying claims whenever possible. One common dispute in workers’ comp cases is whether the injury occurred on-the-job or outside the work environment. Even it is undisputed that the injury happened in the workplace, however, the employee’s behavior in certain circumstances may be used to justify a denial of benefits.

Willful misconduct is one of the key defenses insurance companies use to avoid paying injury claims. In the case mentioned above, willful misconduct was an adequate defense for the workers’ comp insurer because the employee was violating a clear, substantive workplace policy by keeping the loaded pistol in his truck, and he did not provide adequate justification for his actions.

However, you can always contest that your performance rose to the level of “willful misconduct.” Willful misconduct involves insubordination, violation of a work rule, excessive absenteeism or other activity that indicates the employee is intentionally disregarding the employer’s interest. On the other hand, if the employee does not live up to the employer’s standards because of inexperience, incompetence, inability to perform the work or due to honest mistakes, the employee’s behavior does not qualify as willful misconduct.

Denial Based On Other Behavioral Justifications: Horseplay, Self-Infliction and Intoxication

Horseplay, the intentional self-infliction of injuries and intoxication are all also defenses that the workers’ compensation insurer may raise based on an employee’s behavior.

In Pennsylvania, a worker may still be eligible for workers’ compensation if the injury arose out of horseplay. Workers’ compensation may be denied only if the horseplay was so disconnected from the injured employee’s regular work duties as to make the worker essentially a trespasser at the workplace.

If an injury is intentionally self-inflicted, the workers’ comp insurer is never obligated to provide benefits under Pennsylvania law. However, the burden is on the employer and/or the insurer to prove that an injury was both intentional and self-inflicted if these grounds are to be used to deny workers’ comp benefits.

Intoxication or illegal drug use can also be grounds to deny an employee workers’ compensation benefits. Under Pennsylvania law, if an injury would not have occurred but for an employee’s intoxication or illegal drug use, that employee is not eligible for workers’ compensation. This does not mean that any employee who was intoxicated or had used illegal drugs is always automatically ineligible for workers’ comp — for instance, if an injury would have happened whether the employee was impaired or not, intoxication or illegal drug use may not be relevant in terms of workers’ compensation.

Talk To a Pittsburgh Workers’ Compensation Attorney to Get Full Benefits

If you are facing a denial or undervaluing of your workers’ compensation claim, don’t be afraid to fight back. You are entitled to workers’ compensation benefits for a job-related injury or illness, and your employer is always prohibited by law from retaliating against you for making a workers’ compensation claim.

Get the benefits you deserve: talk to a Pennsylvania workers’ compensation attorney today.

Keywords: Pennsylvania, Workers’ compensation, willful misconduct, workers’ comp, denial
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