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What types of injuries does workers' compensation not cover?

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Q:

What types of injuries does workers' compensation not cover?

A:

Workers' compensation claims can be complicated when the conditions surrounding the injury are questionable with respect to employee activity at the time of the injury. Workers' compensation insurance protection is designed to cover employee injuries that occur during the discharge of work duties, so merely being at work at the time of an injury may not be sufficient for a valid claim in some cases. This determination can also depend on the state of employment when state legislation allows certain conditional claims approvals.

Unacceptable Injury Conditions

The issue of a worker's compensation claim approval involves what the employee was doing more than what type of injury they suffered. Acceptable workers' compensation injuries occur when the injuries arise within the "scope and course" of employment. If the worker is performing a common work responsibility at the time of the injury, then the injury is probably a valid worker's compensation injury.

Some injuries are not severe enough to keep the employee from performing some type of work duty, so employers may opt to put the employee on light duty of some type. This situation can even include headaches in some cases, but exposure to toxic chemicals that cause constant medical problems could qualify. Any injury that occurs when an employee is off duty is not generally an acceptable workers' compensation injury; this usually includes injuries that occur while commuting to and from work. Claims from injuries that occur while in transit performing official work duties are usually approved.

Misconduct and Breaks

Injuries that occur due to horseplay or prohibited activities at work are normally not claimable injuries, but the employer may choose to file an injury report and possibly conduct a drug test. Any injury that occurs on employer property outside of the scope of duty may still be covered by standard premises personal injury protection, so an injury report may be necessary in some instances.

This is usually for the legal protection of the employer. Misconduct can provide evidence of reasonable assumption of risk with no employer negligence involved. Injuries that occur during scheduled unpaid breaks are normally not recoverable, such as during lunch, but this may be questionable if they occur during a paid break. By law, most employers are required to provide paid breaks.

Pre-Existing Conditions

Anyone with a prior medical condition before beginning employment may be denied workers' compensation coverage if the condition worsens unexpectedly due to work conditions. However, this employee exemption may not apply when the employee is injured over time with a repetitive motion disorder that has worsened a pre-existing problem that did not keep the employee from performing job duties.

The employer accepted the condition when hiring the employee. Repetitive motion disorder cases can be difficult to prove in a workers' compensation claim, but the injuries can still be classified as acceptable for compensation if the material case facts are sufficient. Claim denials are not always automatic.

The truth is that injuries filed as workers' compensation cases that do not result from an obvious work-related accident are often contested by both the employer and the workers' compensation insurance company. Even with an arbitrary state workers' compensation board, work injury cases can still be complicated. This situation can be especially true when work is being performed in remote locations or the employee is in a salaried position.

In addition, some states allow exemptions for an employer's requirement to carry workers' compensation insurance, usually based on the number of employees. There may be some work insurance business protection in place, but collecting standard compensation is difficult. It is important to always discuss any work-related injury with a personal injury or workers' compensation attorney who understands the laws of the state and how to proceed with a standard personal injury case.

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