Could Carrier Deny Claim of Foreman who Fell Twice on Same Day?

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A carrier or employer may be able to issue a “back-up denial” of a claim it has already accepted if it turns out that it was misled by the claimant. A case involving a foreman who fell from a ladder at work, and from his son’s roof, on the same day – but only reported one of the falls – illustrates what it might take for a carrier or employer to revoke its acceptance of a claim.

They say lightning rarely strikes twice. Falls, however, sometimes come in pairs. Take the case of a foreman who fell from a ladder at work on Aug. 9, 2021, and filed a claim for injuries. After accepting the claim, the adjuster finally received some additional records she had been trying to get. They showed that on Aug. 9, after he went home, the worker fell off a roof.

The carrier issued a back-up denial. In doing so, it relied on the recently arrived records: 1) an ambulance report relating to the fall from a roof; 2) an emergency room report (stating the claimant “was up on the roof installing his son's AC unit when he slipped and fell off the roof onto the grass"); and 3) a 911 call placed by the claimant's wife.

There was, however, evidence that while working on Aug. 9, the claimant did indeed slip and fall while climbing an access ladder. The claimant challenged the revocation of his claim, arguing that the carrier based its decision on its incorrect view that there had only been one fall–the one at his son’s home. The Workers' Compensation Board affirmed the denial, and the claimant appealed.

A workers’ carrier may revoke its acceptance of a claim and issue a denial at any time when the denial is for misrepresentation by the worker. The insurer must establish that the misrepresentation was material by showing that its decision to accept the claim "could reasonably have been affected" if the true facts had been disclosed. This is known as a "back-up" denial.

Was the carrier entitled to retrospectively deny foreman’s claim?

A. Yes. The new information might reasonably have affected the adjuster’s decision.

B. No. Because the claimant actually fell at work as well, the carrier had no basis for revoking its acceptance.

If you selected A, you agreed with the court in Alvarez v. Safe Corporation, No. A184005 (Or. Ct. App. 12/17/25), which affirmed the board’s decision.

The court pointed out that the carrier accepted the claim based on the claimant’s statements that he had been injured at work. His failure to mention that he had also fallen off the roof of his son’s house led the carrier astray. If the carrier had known of the other fall, that information likely would have impacted its decision.

Further, this was not a situation where the adjuster knew about the claimant’s misrepresentation before she accepted the claim. At the time that the adjuster made her decision, she did not have the ambulance report and other documentation that would have alerted her to the other fall. 

The carrier thus established that the claimant misrepresented the true cause of his injuries and that the carrier’s decision to accept the claim could reasonably have been affected by that misrepresentation. 

Do you have questions about workers' compensation denials? Simply Research has answers.

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