What Workers’ Compensation Doesn’t Cover

As an employer, it is essential to know what you’re responsible for in terms of employee safety and financial liability. It’s your duty to purchase a workers’ compensation insurance policy to protect yourself and your employees in the case of a work-related injury or illness. But what injuries and illnesses do workers’ comp insurance cover? Or, more pertinently, depending on your current situation, what incidents do not qualify for coverage?

Commuting:

Should an employee get into a car accident on their way to or from work, they do not qualify for workers’ compensation benefits. Generally speaking, if the employee is not on company property or completing a work-mandated duty, they do not qualify for a compensation package. Keep in mind that the insurance can cover accidents that occur while the employee is outside of the office or worksite for work-related business, traveling for special employer-approved tasks, or if their job does not have a fixed place of business.

Self-Inflicted Injuries:

Workers’ compensation insurance providers do not cover intentional self-inflicted injuries. This stipulation prevents employees from taking advantage of the insurance coverage and purposely harming themselves to receive benefits. Who has the burden of proof in these situations depends on state legislation.

Under the Influence:

Being under the influence can eliminate an employee from receiving workers’ compensation benefits. However, the use of drugs or alcohol itself is not the reason for benefit denial. If being intoxicated or under the influence is determined to be the cause of injury or illness, the insurance provider will deny the claim. Should your employee sustain an injury while under the influence, but their intoxication was not a direct cause of the accident, they may qualify for workers’ compensation benefits.

Also Read: 4 Things to Look Out For When You Choose Insurance

Broken Protocol:

Businesses have protocols and safety regulations for a reason. Should an employee break these rules, they jeopardize their right to workers’ compensation for any resulting injury. Horseplay, intentional disregard for protocols, and general behavior not furthering business goals is not within your employees’ scope of employment. Therefore, an injury resulting from such behavior is not covered.

However, should an employee’s derivation from the rules cause injury to another employee who did not engage in the dangerous behavior, workers’ comp typically does cover their medical expenses.

As an employer, it is important to implement safety training, have clear and readily available regulations, and reprimand those who don’t follow the rules.

Injuries in Question:

Some employers understand workplace injuries as ONLY injuries that happen on-site as the result of a specific accident. However, this isn’t always the case. In many situations, workers’ compensation insurance DOES cover the following:

  • Offsite Work Vehicle Accidents– When an employee is working offsite—completing business required in their scope of employment—their injuries are covered under workers’ comp.
  • Illnesses That Develop Over Time– Many conditions and illnesses such as carpal tunnel syndrome or respiratory conditions from repeated exposure do count as workplace illnesses. This applies only if the development of these conditions results from repeated events associated with employees’ scope of employment. Employees across all industries often experience cumulative trauma injuries frequently.

Depending on the specific circumstances, workers’ compensation may not cover:

  • Employee Injuries During Work Breaks– If an employee takes a break within the company break room or cafeteria, their injuries may be covered by worker’s comp. However, should an employee leave the workplace, and get injured while on break, injuries are only covered if that break included work-related activities benefiting the employer.
  • Mental Health Conditions– Most states have regulations regarding the coverage of mental health conditions and stress-related conditions. In some cases, employees may be able to file a claim for work-related mental health issues, but the extent of benefits may depend upon their state of employment.

Employees have the right to file workers’ comp claims in these situations. If they are unsatisfied with the insurance provider’s compensation package, they can initiate the workers’ comp settlement process.

Although the exact process varies by state and employee, this alternative allows an employee to seek a monetary settlement as either a lump sum or a recurring payment. The employee and their lawyer will decide upon the monetary amount they feel should be paid for their injury or illness and then contact the insurance company with their proposal.

Coverage Isn’t Always Guaranteed:

While workers’ compensation insurance helps employers and employees in the event of a work-related injury, some incidents are not covered. Even with set standards set by the state, unusual incidents do occur. As an employer, you should stay vigilant about workplace safety and be aware of what responsibilities you have to your employees.

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