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What Injuries Are Not Covered In Worker’s Compensation?

What Injuries Are Not Covered In Worker's Compensation?

In simplest terms, workers’ compensation provides financial and medical benefits to employees who have sustained an injury or developed an illness or disability due to their job. The injuries vary from a sprain to unfortunate deaths, as Osha reports that 5,333 workers died on the job in 2019. Hence, a business must have worker’s compensation regardless of the state it operates in for the benefit of the employees and the employer. There are various types of workers compensation insurance scehemes. If you’re a business that doesn’t know the perks of worker’s comp insurance, learn what it is here.

While the general rule for a claim to be accepted is to have a causal relationship between the injury and the scope of employment, there are specific exclusions from worker’s compensation too. These exclusions do not focus on the type of injury but the cause of the damage. An employee will not be compensated for an injury sustained:

While committing a crime:

Breaking a leg is covered, but breaking the law will not be compensated.

Under the influence of alcohol or drugs:

Most states do not require the employer to pay if the injury sustained is due to “reckless behavior” caused by intoxication. Although an employee can prove that the injury would have occurred even if they were not under the influence, compensation is possible.

If the injury is self-inflicted:

Employees cannot sue their employers for harming themselves simply because it occurred on workplace premises, especially if the injury was intentional.

If the injury is the result of restricted activity or violation of a policy:

Disregarding safety rules or indulging in specifically restricted activities amounts to violations used for rejecting claims.

If the injury occurs outside the scope of employment:

  • While this includes commuting to and from work, an offsite conference, traveling from one facility to another, and even running a work errand are all compensable.
  • Suppose the injury occurs during fighting or “horseplaying” among employees or harmless office pranks. However, your claim will have a chance if you are an innocent bystander or your employer is generally tolerant of shenanigans.
  • If the injury is sustained during recreational activities like company picnics or holiday parties, or other social events, in most cases, claims will be rejected. In case attending the social event benefits the employee, the claim may be heard.

Pre-existing conditions

There is no need to be disheartened if you have pre-existing conditions; while specifically those may not be covered, you would still qualify if those conditions are worsened due to current employment.

While these are generally exceptions, an employer is not entirely exempt too. If an employee can prove that injuries were caused by:

  • Intentional violations of law, such as OSHA by the employer
  • Breach of legal duties as landlords, essential service providers, or manufacturers
  • By firing/demotion to discourage employees from filing a worker’s compensation
  • Damage to employee’s property
  • Or if they were intentioned by the employer out of malice or were reckless
  • Handling of workers’ compensation claims in bad faith
  • Defamation or any other form of discrimination can lead to lawsuits

Workers’ compensation is a right of the employees; it protects their well-being against the risk of employment. While the degree of risk varies from construction workers to office employees, it is absolutely necessary to be protected from such risks, even for employers. Worker’s compensation is a tool that lets employers guarantee their employee’s safety and recovery and safeguards employers from frivolous lawsuits. But just like any other insurance, the process can get lengthy, and the cost of employee recovery really racks up when the recovery is slow, which is why you need to pick out your insurance provider carefully. The efficiency of settling claims as well as the coverage of the care should be the deciding factors. Workers’ comp insurance determines how well-liked your business is, so choose carefully.

About the author


Steven Ly

Steven Ly is the Startup Program and Events Manager at TheNextHint Inc. She recruits rockstar startups for all TC events including Disrupt, meetups, Sessions, and more both domestically and internationally. Previously, she helped produce Dreamforce with Salesforce and Next '17 with Google. Prior to that, she was on the advertising teams at both Facebook and AdRoll, helping support advertisers in North America and helped grow those brands globally. Outside of work, Priya enjoys Flywheel, tacos, the 49ers, and adventuring around the globe.

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