Compensability Denial (Course and Scope)
This letter is used when a Workers' Compensation claim is denied because the injury did not occur during the course and scope of employment.
5-Part Explainability Structure
1. Factual Summary
On [Date of Loss], you reported an injury involving [Brief Description of Incident]. Our investigation included a review of [Employer Statements/Witness Accounts/Video Footage]. We found that at the time of the incident, you were [Factual Reason, e.g., commuting to work/performing a personal errand/outside of authorized work areas].2. Policy and Statute Reference
Under Workers' Compensation law, an injury is only covered if it arises out of and occurs in the course and scope of your employment. This means the injury must happen while you are performing duties for your employer or acting in their interest.3. Analysis and Application
In this case, the facts show that the incident occurred while you were [Specific Detail]. Because this activity was not related to your job duties and did not happen while you were working, it does not meet the legal requirement for a "course and scope" injury.4. Statement of Denial
Based on our investigation and the law mentioned above, we are denying your claim for Workers' Compensation benefits. No payments will be made for medical treatment or lost wages related to this incident.5. Notice of Appeal Rights
If you disagree with this decision, you have the right to challenge it. You may file a claim with the state Workers' Compensation Board or Commission. We recommend you contact them directly for information on the filing process and deadlines. You also have the right to consult with an attorney.Adjuster Guidance
- Ensure the factual summary is objective and based on documented evidence.
- Do not use legal jargon like "heretofore" or "pursuant to."
- Confirm that the "all" jurisdiction template is appropriate or if a state-specific form is required (Phase 5).