Good Cause – What Injured Workers Need To Know

The topic of "good cause" has created extensive conversation in the past few years in an industry dedicated to providing quality alternatives to workers’ compensation. PartnerSource has led the industry in advising on and amending language to incorporate a good cause definition and plan provisions to determine the applicability of good cause when an injured worker fails to comply with certain provisions of their employer’s injury benefit plan. These updates support the plan administrator’s role as a fiduciary, ensuring that unusual circumstances do not prevent an injured worker from accessing available plan benefits.

Not all injured workers understand the use of good cause or in what instances good cause may be applicable to their claim. PartnerSource advocates for providing guidance to injured workers as to when and how to assert a good cause exception to further ensure that the administrator is immediately aware of any extenuating circumstances that may excuse the injured worker’s failure to comply with the plan.

As an example, here is the story of how one injured employee asserted good cause and avoided an unfair application of the plan rules:

Toward the end of a workday, a team member injured her back while performing a lift at work. She was able to complete her shift and returned to work the next day. As the morning progressed, however, her back pain increased and she was allowed to leave work early. Six days after the incident, the injured team member requested medical care, and the HR manager filed the injury claim at that time care was requested. When asked about timely reporting, the injured team member said she had told her team lead about the injury within 24 hours, but the team lead did not confirm that the employee had reported a work injury. The employer’s plan required all injuries be reported within 24 hours of the accident, and the claim was denied.

In her appeal, the injured team member provided pictures of her timecards for the day of the injury and the day after. She also provided screen shots of text messages with her team lead from 10 a.m. the morning after her injury, wherein she advises that she is experiencing significant back pain and asks if another team member could come in early. Also, at 11:00 a.m., she explained her injury to the team lead via text message and requested to go home, an early release that was supported by the employee’s timecard. The final review officer determined that the text messages confirmed that the team lead was aware of a back condition. Based on the totality of the circumstances, it was determined that the team lead knew or should have known that the back pain was related to work. The injured team member’s benefits were reinstated, citing the application of good cause.

This injured team member understood that further information was needed to support timely reporting of her claim, but not every injured worker understands how to overcome a failure or perceived failure to comply with the plan. To ensure injured workers are provided proper guidance, PartnerSource has prepared enhanced good cause language to incorporate into our clients’ plan documents and is reaching out to our clients to further discuss the recommended updates. In our shared mission to create better medical outcomes for injured workers and help companies take great care of their most important asset – their employees – this kind of approach can create excellent value for PartnerSource clients and their workforces.

For any questions about good cause, please contact your PartnerSource team leader or director today.