Workers compensation is supposed to provide a safety net for employees injured on the job. But the system has limitations and exclusions that leave some injured workers without coverage. Understanding why certain workplace injuries don’t qualify helps you identify alternative paths to compensation when your claim gets denied.
Our friends at Polsky, Shouldice & Rosen, P.C. discuss how workers comp denials don’t always mean you have no legal options. A construction accident lawyer can evaluate whether you can pursue a traditional lawsuit against your employer or third parties when workers compensation doesn’t cover your injury.
Independent Contractors Aren’t Covered
Workers compensation only covers employees, not independent contractors. Many companies misclassify workers as contractors to avoid paying benefits and insurance premiums. If you’re classified as an independent contractor, you won’t have access to workers comp when injured.
The distinction between employee and contractor depends on multiple factors beyond what your employer calls you. Courts examine who controls your work, whether you use company equipment, how you’re paid, and whether you work for other clients. You might legally be an employee even if your employer treats you as a contractor.
Misclassified workers can challenge their status and potentially access workers compensation. Alternatively, they may be able to file personal injury lawsuits against the business that hired them, an option not available to traditional employees.
Injuries Outside The Scope Of Employment
Workers comp covers injuries that arise out of and occur in the course of employment. Both elements must be present. Getting hurt at work doesn’t automatically qualify if you weren’t performing job duties at the time.
Horseplay and pranks between coworkers often fall outside coverage. If you’re injured while goofing off or engaging in activities unrelated to work, your claim may be denied even though the injury happened on company property during work hours.
Personal errands during work time typically aren’t covered. Injuries sustained while running personal errands, even if you’re technically “on the clock,” don’t qualify as work-related. The activity must serve your employer’s interests.
Commuting To And From Work
The general rule excludes injuries that occur during your regular commute. Getting hurt driving to work in the morning or heading home in the evening typically doesn’t qualify for workers comp benefits, even though you wouldn’t be commuting if not for your job.
Exceptions exist for employees whose job involves travel. Salespeople who drive between client locations, delivery drivers, and workers whose duties begin when they leave home often have coverage for commuting injuries.
If you’re running a work errand during your commute or transporting company equipment, you might have coverage. The key is whether the activity serves your employer’s interests beyond simply getting you to the workplace.
Intoxication And Illegal Drug Use
Most states deny workers compensation when intoxication or illegal drug use substantially contributed to the injury. Failing a post-accident drug test often results in claim denial, though the specific rules vary by jurisdiction.
Some states presume intoxication caused the injury if you test positive, shifting the burden to you to prove the substance didn’t contribute to the accident. Other states require the employer to prove intoxication was a substantial factor in causing the injury.
Prescription medications typically don’t trigger this exclusion unless you violated usage instructions or your impairment from the medication caused the injury. The key distinction is between legal medications taken properly and substances that impair your ability to work safely.
Intentionally Self-Inflicted Injuries
Workers comp doesn’t cover injuries you intentionally inflict on yourself. This exclusion prevents fraudulent claims but can also affect legitimate situations where intent is disputed.
The standard focuses on whether you intended the injury itself, not just the action that caused it. Attempting suicide at work clearly falls under this exclusion. But taking a known risk at your employer’s direction might still be covered even if injury was predictable.
Horseplay cases sometimes blur this line. If you’re injured during roughhousing you initiated, the claim might be denied as intentional. If you’re injured by a coworker’s prank, coverage typically applies because you didn’t intend the injury.
Fighting With Coworkers
Physical altercations at work receive varying treatment depending on what caused the fight. Work-related disputes between employees typically qualify for coverage. Personal disputes unrelated to work generally don’t.
If a disagreement about job duties or work assignments escalates to physical violence, the resulting injuries usually fall within workers comp coverage. The injury arose from employment even though the response was inappropriate.
Fights stemming from personal relationships or non-work conflicts don’t qualify. Romantic disputes, arguments about personal matters, or violence motivated by off-duty conflicts fall outside the scope of employment.
Violating Company Safety Rules
Violating workplace safety policies doesn’t automatically disqualify your claim, but it can in certain circumstances. Minor violations that don’t show reckless disregard for safety typically don’t prevent recovery.
Serious and willful violations of safety rules that demonstrate intentional disregard for your safety can bar claims in some states. The bar is high, requiring proof that you knew the rule and chose to violate it despite understanding the risks.
Most routine rule violations don’t trigger this exception. Forgetting to wear safety glasses or taking a shortcut through a restricted area usually doesn’t constitute the level of willful misconduct required to deny benefits.
When Third Parties Cause Workplace Injuries
Workers compensation typically prevents you from suing your employer for workplace injuries. However, when a third party causes your injury at work, you often have options beyond workers comp.
Common third-party workplace injury scenarios:
- Defective equipment manufacturer liability
- Negligent contractors or subcontractors
- Delivery drivers who cause accidents
- Property owners where you’re working
- Vendors or clients who act negligently
Third-party claims allow you to recover damages workers comp doesn’t cover, including pain and suffering, full lost wages, and punitive damages. These personal injury lawsuits proceed separately from any workers compensation claim.
Independent Business Owners And Partners
Business owners, partners, and corporate officers often aren’t covered by workers compensation policies. Many states exclude these individuals from mandatory coverage because they control the business and can choose whether to purchase insurance.
Sole proprietors working alone typically don’t qualify for workers comp benefits when injured. Some states allow business owners to opt into coverage, but it’s not automatic.
Limited liability company members and corporate shareholders who actively work in the business may or may not be covered depending on state law and policy specifics. These classification questions become important when injuries occur.
Volunteers And Unpaid Workers
True volunteers generally don’t receive workers compensation coverage. The system is designed for employees who receive compensation for their work. Unpaid individuals performing charitable work fall outside this definition.
Exceptions exist for certain categories of volunteers. Firefighters, emergency responders, and other public safety volunteers often receive coverage under special provisions. Some states extend coverage to specific volunteer categories by statute.
Unpaid interns occupy a gray area. Those performing work similar to paid employees as part of educational programs might qualify for coverage depending on state law and the nature of their relationship with the employer.
Agricultural And Domestic Workers
Some states exclude agricultural workers from mandatory workers compensation coverage, particularly on small farms or for seasonal labor. Domestic workers like housekeepers, nannies, and home health aides also face limited coverage in certain jurisdictions.
These exclusions reflect historical exemptions that continue in some states despite efforts to expand coverage. Workers in these industries may have no recourse through workers comp when injured on the job.
Federal employees follow different rules under the Federal Employees Compensation Act rather than state workers compensation systems. The eligibility requirements and benefits structure differ from typical state programs.
Alternative Legal Options After Denial
A workers compensation denial doesn’t always mean you’re out of options. You can appeal the denial through your state’s workers comp system, potentially overturning the decision with additional evidence or legal arguments.
If your employer didn’t carry required workers compensation insurance, you might be able to sue them directly for your injuries. This removes the usual immunity employers enjoy under workers comp laws.
Third-party claims remain available regardless of workers comp status. Pursuing the manufacturer of defective equipment, negligent contractors, or other parties who contributed to your injury can provide compensation when workers comp doesn’t.
Understanding Your Rights
Workplace injury cases involve overlapping systems with different rules, exclusions, and remedies. What seems like a straightforward workers comp claim might actually require a personal injury lawsuit, or vice versa. The specific facts of your situation determine which legal path provides the best opportunity for recovery.
If your workers compensation claim was denied or you’ve been injured at work under circumstances that don’t fit typical workers comp coverage, reach out to discuss your situation and explore all available legal options for recovering the compensation you need.