California is a state that requires employers to provide workers’ compensation. However, this does not mean that they have to pay every claim. There are some terms and conditions on claims that fail to meet legal standards. Here are some of them.
What is AOE/COE?
Under California Labor Code § 3600, an injury must happen out of and in the course of employment (AOE/COE) to be covered. This rules out injuries occurring during a commute or personal break unrelated to work, or a preexisting condition that was neither caused nor aggravated by work activities.
Employee misconduct
The Labor Code also allows denial of claims when the employee’s own conduct is at fault:
- Intoxication: If the injury was proximately caused by the employee’s use of alcohol or drugs, the claim can be denied.
- Initial aggressor: Denial applies when the injured worker was the initial physical aggressor in an altercation.
- Felony commission: Injuries sustained while the employee was committing a felony of which they have been convicted are not covered.
- Self-inflicted injury: Intentional self-harm is excluded from coverage.
If proven, these conditions can also be a part of disciplinary action within the company policies.
The 90-day rule
This rule is crucial for both employers and employees:
- Presumption of acceptance: The employer (or its insurer) must notify the employee of acceptance or denial within 90 days after the employee files the DWC-1 claim form.
- Consequence of silence: If no formal denial is issued within this 90-day window, the claim is deemed “presumed accepted” under Labor Code § 5402.
Once that deadline passes, it is extremely difficult to reverse course.
The importance of a lawyer
Complex issues like these are why businesses need specialized California employment law defense attorneys. Skilled counsel can help you meet the 90-day deadline, thoroughly investigate allegations of intoxication or misconduct, and avoid costly mistakes that can lead to automatic acceptance of liability.