The workers’ compensation system provides benefits to workers who are injured on the job. The system is considered a no-fault system, which means that workers don’t need to prove that anyone was at fault for their injuries in order to receive benefits.
Nevertheless, insurance companies come up with all kinds of reasons to deny a claim. One of the more common reasons is to claim that an injury is “idiopathic.”
Let’s take a closer look at what it means to claim that an injury is idiopathic in the context of workers’ compensation.
What constitutes a compensable workers’ compensation claim?
To receive workers’ compensation benefits in most states, you must prove that your injury “arose out of and in the course of your employment.”
In other words, you need to prove that there is some causal connection between the conditions under which you had to work and your resulting injury.
This point can be a little confusing, so let’s take a look at a couple of real cases.
In Cartersville City Schools v. Johnson, Celia Norris Johnson, a fifth-grade teacher, fell and injured her knee while weaving between desks that were tightly grouped together in her classroom. Celia filed a workers’ compensation claim.
The administrative law judge (ALJ) found that Celia’s knee injury was causally connected to her employment and granted workers’ compensation benefits.
Specifically, the ALJ determined that Celia’s “necessary swift movements and the configuration of her classroom caused her to place acute stress on her knee, resulting in the injury she sustained." The ALJ went on to explain that these "external factors created a risk and caused a danger which was peculiar to her work environment, which causally connects her employment to her injury."
In Frett v. State Farm, Rochelle Frett was injured when she slipped and fell on some water in her employer’s break room during a mandatory lunch break. She filed a claim for benefits, but the State Board of Workers’ Compensation denied her claim. Rochelle appealed the denial.
Ultimately, the Georgia Supreme Court sided with Rochelle, finding that “there was a causal connection between the conditions under which the work was required to be performed [water on the floor of the breakroom] and the resulting injury.”
What is an idiopathic injury?
An injury is considered idiopathic if there’s no causal connection between the employee’s injury and the conditions under which the employee is required to work.
As the Georgia Court of Appeals explained in Cartersville:
“An injury that is peculiar to the individual or arises spontaneously from an obscure or unknown cause and has no causal connection to workplace activity or conditions is idiopathic and does not constitute an injury arising out of employment.”
Perhaps the most well-known case involving an idiopathic injury is Stoker v. Walker County Board of Education.
In Stoker, a substitute teacher, Annie Stoker, was leading her class from the cafeteria to the classroom when she suddenly fell and fractured her hip. Annie testified that she didn’t see any substance or foreign object on the ground, nor did she have any idea why she fell. She was simply walking at a normal pace along a long straight hallway with a smooth, flat surface one moment and on the ground the next.
The court found that Annie’s injury was idiopathic because she failed to prove that her injury arose out of her employment. In other words, Annie failed to prove that there was a causal connection between the conditions at work and her injury.
Meet Georgia workers’ compensation attorney Ben Gerber of Gerber and Holder.
“While it is possible to receive workers’ compensation for an idiopathic injury, the road to compensation can be difficult—as Ms. Stoker’s case attests to. In order to qualify for workers’ comp, the law states that the injury sustained must be directly connected or ‘arise out of and in the course of employment.’ Since, by definition, idiopathic injuries don’t have an explainable origin, it can be challenging to prove that they arose from employment.”
The attorneys at Gerber and Holder offer FREE initial consultations.
Filing an appeal after receiving a workers’ compensation claim denial
If the insurance company claims that your injury is idiopathic and denies your claim, all hope is not lost.
All states have a process for appealing a workers’ compensation decision. In most cases, a decision must be appealed within 30 days. If you choose to appeal a decision, keep in mind that the process can be complicated and is best handled by an experienced workers’ compensation attorney.