Workers’ compensation insurance is one of the best safety nets for employees who suffer illness or injury related to their job. However, many workers are surprised that workers’ compensation coverage doesn’t include several injuries and illnesses.
If you’ve been injured or fallen ill because of your job, seeking workers’ compensation is the best way to ensure you have the financial means to heal. Knowing what is and isn’t covered under workers’ compensation insurance will help you start the claims process with realistic expectations.
What is Typically Covered if You Carry Workers’ Compensation Insurance?
Workers’ compensation insurance protects employees and employers when workplace injuries or illnesses occur. This coverage typically includes:
- Medical expenses related to workplace injury or illness
- Rehabilitation costs to help the employee return to work
- Disability benefits for temporary or permanent disabilities from workplace injury or illness
- A portion of lost wages during the recovery period
- Death benefits for families if an employee dies because of a work-related incident
Workers’ compensation benefits are usually provided regardless of who was at fault for the incident as long as it happened within the scope and course of employment.
Common Exclusions: Injuries and Illnesses Not Covered
Though workers’ compensation insurance covers many work-related injuries, several injuries and illnesses aren’t included.
Injuries Occurring Outside of Work
Workers’ compensation payments don’t cover any injuries or illnesses outside the course and scope of employment. Some examples of incidents outside of workers’ compensation coverage are:
- Accidents that occur during lunch breaks unless you were performing a work-related task during that break
- Injuries sustained during your commute to and from work (also known as the coming and going rule)
- Accidents that happen at a voluntary company-sponsored event and aren’t directly related to work duties
- Injuries that occur while running personal errands, even if you’re in a company vehicle
It’s important to remember that there are exceptions to these exclusions. If you must travel for work or run an errand at your employer’s request, your injuries can still be within the coverage.
Self-Inflicted Injuries or Illnesses
Workers’ compensation covers accidental workplace injuries and occupational illnesses but typically excludes intentional or self-inflicted conditions. Common exclusions include:
- Self-harm or suicide attempts
- Injuries resulting from an employee starting an altercation or fight at work
- Health issues resulting from an employee’s engagement in illegal activities
- Injuries or illnesses caused by the employee’s intoxication or substance abuse
The line between intentional and accidental can be blurry, especially when mental health issues are involved. That’s why having an experienced workers’ comp attorney who can evaluate your specific circumstances is beneficial when determining coverage eligibility.
Pre-Existing Conditions
While workers’ compensation generally doesn’t cover pre-existing conditions, work-related aggravation of these conditions may be compensable. Here’s how pre-existing conditions affect your claim:
- If your pre-existing condition worsens because of your job duties, you might be eligible for workers’ comp coverage. Still, that coverage only applies to the portion of the condition that was worsened due to work.
- You’ll need a medical evaluation that proves that your work activities worsened the condition.
- Workers’ comp coverage can be limited to the medical treatment necessary to return to your pre-injury state instead of treating the underlying condition.
Let’s say you have a back injury that got worse after lifting something heavy at work. You might be able to secure coverage for the additional treatment necessary to heal but not for any treatment you received prior to the condition worsening.
Mental Health Conditions (With Exceptions)
Mental health coverage under workers’ compensation is complicated and can vary by state. More often than not, mental health conditions that aren’t accompanied by a physical injury aren’t covered under workers’ compensation. There are exceptions, such as:
- Some states recognize mental health conditions caused by extraordinary workplace stress or traumatic events as compensable.
- Mental health conditions that directly stem from a work-related injury are often covered.
- Occupations with high-stress or potentially traumatic experiences, like law enforcement and other first responders, might have broader coverage.
Injuries From Horseplay or Fighting
Any injury from fighting, horseplay, or non-work activities within the workplace is usually not considered compensable as these activities aren’t seen within the scope of employment. As with other injuries mentioned, there are exceptions:
- Some states might provide coverage if horseplay is a common and accepted part of the company’s work environment.
- If an employee is an unwilling participant or victim of a fight or horseplay initiated by other employees, they might be compensated if an injury occurs.
- If an employer is aware of horseplay and tolerates it without taking steps to get coverage, they can be held liable, and you’ll have grounds for coverage.
Every case is different and will be evaluated as such. It’s important to consult with your workers’ compensation attorney to determine if your company’s workers’ compensation insurance covers your situation.
Independent Contractors
Since independent contractors aren’t technically considered employees, they’re often not included in workers’ compensation coverage. However, the classification between employee and independent contractor can be complicated and, therefore, contested:
- Some employers will misclassify a worker as an independent contractor to avoid providing workers’ compensation benefits to them;
- Some states have laws that require coverage for certain types of independent contractors, like those in high-risk positions;
- Whether someone is an employee or independent contractor depends on many factors.
Other Circumstances That May Affect Workers’ Compensation Benefits
Other circumstances can impact your ability to qualify for workers’ compensation benefits outside the standard exclusions. It’s important to know what these are to ensure you’re maximizing your chances of receiving the benefits you deserve and protecting your rights.
Failure to Report the Injury Promptly
Reporting your injury to your employer promptly affects workers’ compensation benefits. When you don’t, you can jeopardize your claim in many ways:
- Most states have deadlines for reporting the injury; you’ll likely be ineligible if you don’t do so within the timeframe
- Late reporting can delay your access to medical care and other benefits
- Delayed reporting can make it harder to prove your injury was work-related
- Your employer and their insurance company may question your injury’s severity if you wait to report it
Violation of Company Policies
If an injury happens because someone violates company policy or safety regulations, they might not be covered under workers’ compensation. This violation can include:
- Engaging in prohibited activities on company property
- Failing to use the required safety equipment
- Violating specific safety protocols put in place by your employers
However, just because you violate a policy doesn’t automatically make you ineligible. It all depends on the specific circumstances of your case.
Intoxication or Drug Use
Injuries that happen because you were under the influence are excluded from workers’ compensation. Intoxication significantly increases the risk of injury and shouldn’t be done in the workplace. There are some considerations with this:
- Most states require you to prove that intoxication was the leading cause of injury, not just a contributing factor.
- Some states provide reduced benefits rather than complete benefits if intoxication plays a role.
- If an employer encourages intoxication or tolerates it at work, employees might be entitled to coverage despite being intoxicated.
Challenging a Denial of Coverage
If you’ve applied for worker’s compensation but your claim is denied, or you’re under the impression you’re not receiving your full benefits, you can challenge the decision. You need to understand the appeals process and how a great workers’ comp attorney can help you successfully navigate a claim denial.
The Appeals Process
The workers’ compensation appeals process can vary from state to state, but generally looks like:
- Your employer’s insurance company will send you a denial letter with an explanation
- You’ll file a formal appeal with your state’s worker’s compensation board or commission
- Some states require mediation before a formal hearing
- If mediation isn’t successful or not required, you can go before an administrative law judge
- You’ll present your case to support your claim
- You’ll receive a decision
The Importance of Legal Representation
You can navigate the workers’ communication process alone, but hiring an experienced workers’ comp attorney is beneficial because:
- We have experience and expert knowledge of workers’ compensation laws
- We’ll gather and present compelling evidence to support your claim
- We’ll negotiate with workers’ compensation insurance companies on your behalf
- We’ll represent you at hearings
- We’ll advise you on whether you continue negotiations or settle
Secure Expert Legal Representation!
If you’re struggling with your workers’ compensation claim, the attorneys at Rosenfeld Injury Lawyers are here to help in any way we can. We have the experience and compassion to help you navigate the process from start to return to work. We’ll ensure you fully understand your rights and what you’re entitled to based on workers’ comp insurance.
Book a free consultation with a Chicago workers’ compensation lawyer by calling at (888)-424-5757. We operate on a contingency fee, so you don’t owe us a dime unless we help you recover compensation.