Centurion May 2025 Producers Advisory - West Virginia Workers Compensation Claims Exclusions

Short Answer:

There are a number of reasons that employee injuries or illnesses may not be covered under the workers compensation laws in West Virginia.

Common West Virginia Workers Compensation Claims Exclusions:

1. The employee injury or illness was not sustained “in the course of,” or “resulting from” employment, or both, meaning that the employee did not establish by positive evidence that he or she sustained an injury in the course of their covered employment.

2. The worker was in an employment category that does not qualify in West Virginia for workers compensation coverage such as domestic workers, casual workers, and employees working out of state, to name a few.

3. An employee cannot receive compensation for an “ordinary disease of life to which the general public is exposed outside of employment . . . except when it follows as an incident of an occupational disease.

4. Self-inflicted injuries, or injuries caused by the employee’s willful misconduct (provided such misconduct resulted in a self-inflicted or intentional injury), horseplay or intoxication are not compensable.

5. Any alleged psychiatric condition caused solely by nonphysical means and which does not result in physical injury or disease is not compensable.

6. For an occupational injury claim, the statute of limitations of six months was exceeded.

7. If an employee’s injury was caused by his or her intoxication due to drugs or alcohol the employee is not entitled to receive any benefits.

8. If an employee has a pre-existing injury or illness that is aggravated by their job, the claim may be denied if the job did not worsen the condition, or if the pre-existing condition is the primary cause of the disability.

9. The employee failed to seek medical treatment within a reasonable time.

Additionally, a WV Workers Compensation Claim can be Rejected If:

•  The worker injury notice to the employer did not contain the name and address of the employer; the name and address of the employee; the time, place, nature and cause of the injury; and whether temporary total disability has resulted from the injury.

• The employee was aware of a pending job termination and filed a questionable claim because of it.

The Top-5 Reasons That Workers Compensation Claims are Rejected in West Virginia:

1. The injury did not happen at work.

2. The injury was the result of a preexisting medical condition.

3. The injury was not reported in a timely manner.

4. The claimant failed to seek immediate medical treatment.

5. The worker was intoxicated at the time of the injury.

The West Virginia Workers Compensation Appeal Process:

1. After receipt of the claim, the employer’s claims administrator (usually the workers comp carrier or a third party administrator, TPA) has 15-days to approve or deny the claim.

2. The written order issued by the claims administrator, including the decision on the compensability of the claim, must be sent to the claimant, employer, and any counsel of record.

3. Unless a protest is filed within 60 days of the notice, the decision is final.

4. If a protest is filed, the Workers Compensation Board of Review handles the review process and the claimant can seek representation by an attorney or proceed without one.

5. If the claimant is not satisfied with the Board of Review's decision, they can appeal to the Intermediate Court of Appeals.

6. The claimant has the right to appeal to the Intermediate Court of Appeals any final action taken by the Workers’ Compensation Board of Review.

7. The final appellate step available to the claimant is a review by the West Virginia Supreme Court of Appeals, the highest judicial body in the state.

For Additional Information Contact Rob at: (606)434-0739