GQ Corner
Q: I have a claimant who reported a work-related injury to the employer two years ago, but we only just received notice. Are we automatically liable for benefits at this point?
A. No. The standard 15-day and 60-day timeframes apply, as these are tied to the date the carrier received notice of the claimed work-related injury. Therefore, you have not waived your right to contest the compensability of the claim, should your investigation support this action. Instead, you have 15 days to either dispute the claim or initiate benefits, and a full 60 days to ultimately dispute if you elect to do so. It is critically important here to keep in mind that if you do not raise a dispute by the 15th day, you will become liable for all accrued benefits—both medical and indemnity—and the exposure could be particularly significant given the age of the claim. Consequently, a prompt investigation is crucial so that hopefully you will have the information that you need to make the claims decision by the 15th day.
Q. If a claimant is injured at a holiday party for employees, would that injury be compensable?
A. It depends, but it probably would be compensable in most cases. The general rule that in order for an injury to be compensable, it must arise out of and in the course and scope of employment. This means that the injury must originate in the employment and must have occurred while the claimant was furthering the business or affairs of the employer. Furthermore, Texas Labor Code Section 406.032(1)(D) provides generally that a carrier is not liable for compensation if the claimed injury arose out of voluntary participation in an off-duty recreational, social, or athletic activity that did not constitute part of the employee’s work-related duties. However, the statute qualifies that statement by exempting from its ambit activities that are a reasonable expectancy of or expressly or impliedly required by the employment. This caveat is what usually makes injuries of this sort compensable, given that most employees are at least strongly encouraged (and thus arguably required at least impliedly) to attend work events of this nature.
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