A caller to my office had an unusual, but not unheard of situation.
He injured his back at work in Chicago and reported the accident right away. The accident was on a Tuesday. He, as required by law, took a drug test and failed. He admits he had been partying the previous Saturday.
Normally these cases get denied right away, but in this case they paid his medical bills, including a surgery and all his time off work. He did get fired from the job though for the failed test.
Fast forward nine months later and he gets a letter in the mail from the insurance company that says they’ve reviewed his claim and now are denying his case. To them they consider the case closed.
His question to me was can they do that?
The answer is that payment of benefits is not an admission of liability. In other words, just because they paid my mistake doesn’t mean that they have to pay you forever. In this case, the failed drug test gives them a right to deny benefits. What will happen is that he will hire a lawyer, go to trial and testify (honestly) that he got high on Saturday, was sober by Sunday and completely fine when he was injured 72 hours after he used drugs.
Unless the insurance company has some evidence that he really was high when he got hurt, which they surely don’t, he will win.
The more common example is when someone gets hurt on the job, starts receiving benefits and then is sent to an IME doctor who says the injuries aren’t work related. That gives them the right to stop paying your bills and lost time. It doesn’t mean you lose the case, it just means you likely have to go to arbitration.
What I think happened in this case is that it was assigned to an adjuster who applied common sense. The way this worker was hurt was by being run in to by a co-worker. Even if he was high, he was literally just standing when someone knocked him over. So drugs or not it had nothing to do with the accident. The way insurance companies work though is that once they spend a certain amount of money on a case, a higher level person usually takes over or at least looks at it. They probably saw the failed drug test and decided to act.
It’s a short term inconvenience that is easily solvable with the right lawyer. The good news in this case is that he’s almost done with his treatment so he won’t really suffer.
These things happen. Employers and insurance companies do have rights and they will certainly use them to their benefit when they can. That’s alright because workers have rights too and when the facts are on their side they win in the end.