Workers’ compensation applies on a no-fault basis, even if the injury was caused by the employer’s or employee’s carelessness. In general, all that matters is that the injury arose from employment. There are certain instances in which workers’ compensation does not cover an injury. To understand this, we’ve created a guide for what is covered and what is not. The insured needs to know what their coverage consists of.
Workers’ Comp Coverage Defined
Workers’ compensation covers injuries and illnesses that are within the “course and scope of your employment.” The court has broadly used this rule of thumb to determine the coverage of injuries and the benefits of employees making claims. Typically, the injury will be covered for those involved in an activity that benefits the employer. Those who incur an injury while performing work duties will qualify for workers’ comp. For instance, an employee who slips and falls while working in a restaurant kitchen would be covered. Injuries due to repetitive motion to perform work duties are also within the scope of employment, such as constant grasping at work leading to carpal tunnel syndrome.
On Break Injury
Workers’ comp may still cover an employee who suffers an injury in the company’s break space. It is commonly considered a benefit to the employer when employees remain onsite for meal or rest breaks since this saves time and employees are still accessible to the employer.
Workers who leave the premises of their employment typically don’t qualify for benefits if they become injured on the break, unless doing work-related tasks (i.e. an employee picking up lunches for a meeting).
On-Premise but Clocked Out Injury
A general rule of thumb is that workers comp will cover injuries that take place at the location of an employee’s workplace, even when no longer on the clock. This typically encompasses injuries that occur in parking lots that an employer is responsible for when an employee is coming and leaving for work. However, no injuries will be covered once clocked off and no longer on the company’s premises.
Off-Site Injury
Only injuries that occur due to performing tasks that benefited an employer will be covered when not at work. The injuries must fall within the course or scope of employment, for instance, during professional education or job-related training, or during business travel. Different jurisdictions might have their own tweaks on the rules, so be sure to speak to your insurer to determine the specific eligibility for workers’ comp benefits.
Common Exclusions From Workers’ Compensation
Common scenarios in which injuries are not considered to be in the course and scope of employment:
Commuting To And From Work
Workers’ comp will not cover those commuting to and from work on their regular routine. However, any injuries may fall under this coverage if the employee:
- Is driving a company car
- Has more than one work site
- Is running a work errand.
Recreational Activities
There are many moral-building events that take place at workplaces. Injuries at these gatherings, such as a company picnic or holiday party, are often not covered by workers’ comp unless attendance is mandatory. Keep in mind that workers’ comp applies to the fact-specific injury, so you will need to consult with your insurer on a case by case basis and not assume an injury isn’t covered.
Intoxication or Substance Abuse
Injuries caused by the worker’s intoxication are almost always excluded. Suppose there is proof that the accident could have been prevented and the intoxicated was not at fault (i.e. factory worker struck from behind with a lift truck). In that case, an employee might be able to qualify for benefits. Intoxication defenses are difficult for employers to prove, and these injuries involve a detailed factual and legal analysis.
Workplace Horseplay and Fighting
Practical jokes and arguing are not in the scope of work-related injuries and therefore not usually covered by workers’ compensation unless employers tolerate ongoing horseplay or an innocent bystander. Workers’ compensation does not cover most injuries resulting from workplace altercations unless it is due to a work-related issue. With exceptions to the rules and varying regulations, you are urged to speak with your insurer and workers’ compensation lawyer to evaluate claims and determine the likelihood of success on an appeal.
About Sine Insurance
At Sine Insurance Group, we are dedicated to providing you with custom-tailored insurance policies to protect your assets. Our comprehensive packages have been expertly crafted to serve St. Louis and the surrounding areas for the past 25 years. For more information about our products, contact us today at (855) 700-0889.