Every year, millions of Americans suffer injuries on the job that entitle them to workers’ compensation benefits. In a recent year, U.S. employers reported millions of nonfatal workplace injuries and illnesses, with a significant number resulting in time away from work. Most of these claims are straightforward: workers get medical care and wage support, recover, and return to work. 

However, a small fraction turns into protracted complex claims – long-term injury cases that can stretch on for years, testing the patience of injured workers and the system alike. These cases, often called “legacy” claims, are the outliers that drive a disproportionate share of costs in workers’ comp. Understanding why some claims become so complex and how to address them is crucial for employers, insurers, and workers themselves.

What Makes a Workers’ Comp Claim “Complex”?

Workers’ compensation is meant to be a no-fault insurance system: if you’re hurt at work, your employer (through their insurer) covers medical treatment and part of lost wages, regardless of who caused the injury. However, not all claims follow a smooth path. Complex claims tend to involve serious, hard-to-treat injuries or tangled circumstances that defy the usual timelines for recovery. 

Also known as legacy cases, these claims often drag on for 10 years or more, involve multiple medical issues (co-morbidities), and rack up over $500,000 in reserves. Unsurprisingly, such claims take longer to process and are more likely to be denied at first due to their intricate nature. It’s easy for everyone involved – employers, insurance adjusters, even doctors – to feel overwhelmed by a claim that never seems to resolve.

Why do some workers’ comp cases become so complicated? Often it’s a combination of factors. 

While the vast majority of workplace injuries heal on a normal schedule, a small contingent of claims inevitably “go off track” and drive a huge share of costs. These are the claims with repeated surgeries, chronic pain issues, disputes over treatment, or legal wrangling. Over time, a straightforward injury can morph into a long-term saga due to medical setbacks or administrative hurdles. Below are some common reasons a claim might turn complex:

Severe or unpredictable injuries

Specific injuries – for example, low back injuries, head trauma, or severe burns – have more uncertain outcomes and can lead to complications or chronic pain. If a worker isn’t healing as expected, the case can remain open far longer than usual. In rare instances, severe injuries lead to high-cost claims exceeding millions, making up a small fraction of cases but a notable portion of overall workers’ compensation losses due to extended medical care and long-term disability.

Comorbid health conditions

Suppose an injured worker has other health issues (like diabetes, obesity, or heart conditions) or develops secondary problems such as depression or anxiety related to the injury. In that case, recovery can be slower and more complicated. Managing multiple conditions makes the claim harder to resolve, as treatments must be coordinated and setbacks are common.

Therapeutic and medication complexity

Long-term claims often involve powerful medications (for example, opioid painkillers or complex drug cocktails). Over-reliance on opioids can lead to dependency issues, and juggling multiple prescriptions raises the risk of side effects or drug interactions. If a worker requires costly specialty treatments or devices that can introduce disputes – insurers may question unproven therapies or expensive procedures, adding financial complexity to the claim.

Legal involvement and disputes

An injured worker hiring an attorney is one of the strongest predictors that a claim will become protracted. Disputes may arise if the worker feels benefits are inadequate or the insurer questions the claim’s legitimacy. 

Once lawyers enter the picture, the process can slow down. Claims with attorney involvement take over twice as long to close and cost over twice as much as similar claims without legal disputes. Legal procedures (like depositions, hearings, and appeals) add complexity and strain relations between workers and employers.

System and administrative challenges

The workers’ comp system itself can compound issues. High turnover among claims adjusters – the professionals managing the case – means a claim might get handed off multiple times, causing delays or inconsistent handling. 

Administrative backlogs or insurer cost-containment tactics (such as requiring extensive paperwork for treatments) can slow down approvals for medical care. In some instances, needed treatments get delayed or denied, worsening the worker’s condition and prolonging the claim.

A Collaborative Path Forward

Ultimately, a workers’ compensation system works best when it lives up to its original bargain: providing prompt, fair support to injured workers in exchange for lawsuit protection. Achieving that in complex cases requires diligence, data, and often creativity. But the payoff is worth it – in saved costs, saved careers, and a fairer outcome for those who’ve already paid a price through injury. As the industry learns from past mistakes and new research, the hope is that even challenging claims can find a healthier resolution, turning long roadblocks into success stories.

Disclaimer: This article is for informational purposes only and does not constitute legal, medical, or financial advice. Workers’ compensation laws and policies vary by jurisdiction, and outcomes may depend on individual circumstances. Readers should consult qualified professionals for advice specific to their situation.

Published by Stephanie M.