What’s not covered under workers’ compensation policies?

What’s not covered under workers’ compensation policies? | Insurance Business

What’s not covered under workers’ compensation policies?

Workers’ compensation insurance is a critical coverage that protects businesses and their workforce by providing benefits to employees who are injured on the job. However, there are situations when employees are injured at work, but they are not covered under the workers’ compensation statute.

Robert Schiller, director of eastern zonal operations at AmTrust North America, took Insurance Business through key examples of incidents where injuries would not be covered by workers’ comp policies, though he added that it’s important to keep in mind each state governs workers’ compensation independently. The following situations address generally accepted principles for most jurisdictions.   

First off, what is covered by workers’ comp insurance?

“Although there are some exceptions, generally any injury arising out of, or in the course and scope of employment is covered,” said Schiller.

In fact, the “course and scope” rule should be top of mind when determining whether an employee injury would fall under a workers’ comp policy.

Coming and going rule

As for what would not be covered by a policy, the first situation involves the “coming and going” rule. Someone who has a fixed place of employment, such as an office or worksite, would not be covered when they’re traveling to and from work. However, they would be covered if: 1) they are traveling for business outside of their office or worksite, 2) if they have no fixed place of employment, 3) if they have a special circumstance that’s approved by the employer or 4) they’re on a special mission as directed by the employer. Any of those items would allow for workers’ comp benefits to be paid out should an injury occur, explained Schiller.

Read more: Risks employees face when traveling outside the four walls of a workplace

For example, if an injury occurs while an employee is walking to or from a designated parking lot to the employer’s building within a reasonable timeframe (right before or after work), then that individual would usually be entitled to workers’ compensation coverage. That’s because it’s a place they are expected to be while under the conditions created by the employer. 

On the other hand, a ‘special circumstance’ could be the employer allowing an employee to go to a medical appointment for a work-related injury. If they’re injured while going between the clinic and the employer’s premises, they would generally be covered if they didn’t make a significant route deviation between the two locations.

Horseplay

Another situation where workers’ comp coverage could be called into question is if an injury results from horseplay. Horseplay in general does not further the course of business and is not within the scope of employment, so a resulting injury would not be covered.  

There is, however, an exception for an employee who is harmed during the act of horseplay, but wasn’t directly involved in it.

“For example, if two employees are fighting over something that’s not work-related and one of them is hurt, they would not be covered,” said Schiller. “If somebody walks in and is injured, or tries to break up the fight and is injured, or is hit by an item during that fight, they would be covered because they weren’t party to the act.”

Take two employees working in a warehouse who decide to grab carts that they use to move packages and race around the building. As they make a turn, the cart topples over and one of them suffers a severe injury – they would not be covered, explained the AmTrust director. But, if a cart struck another employee who was just stocking a nearby shelf, that person would be covered since he was an innocent victim and was not party to the horseplay.

Read more: AmTrust report challenges assumptions about workers’ comp

Work from home

With more employers implementing flexible work options, there could also be a question of whether or not employees who work from home would be covered by workers’ compensation insurance in the event of an injury. Generally, employees that work from home are going to be covered for any injury that happens during business hours, says Schiller, but that doesn’t mean that the injury has to occur only between your standard business hours to be covered.

“If somebody is working at night and is injured ascending the staircase to use the bathroom, they’d still be covered even though it doesn’t fall during the regular nine-to-five business hours,” explained Schiller. “It’s very difficult to deny coverage on a case when somebody is injured at home because it’s difficult to prove that they weren’t actually in the course and scope of employment at the time, especially if they’re logged into a computer.”

Intoxication

Next up, intoxication, which in and of itself is not a cause or reason to deny workers’ comp benefits in most states. Specifically, the intoxication of the employee generally has to be the cause of their injury to not be covered. For instance, if they are driving for work and are under the influence, and end up in an auto accident, they generally would be denied workers’ comp benefits. However, if an employee is walking along the street to deliver a package and is intoxicated, and they get hit by a car, they would be entitled to those benefits because the fact they were intoxicated was not the cause of the accident.

The takeaway for workers’ compensation insureds is that a lot of incidents involving worker injuries have to be determined case by case.

“There are set standards for all of these items and for each type of injury, and there are requirements that have to be met,” said Schiller. “Some specific incidents are unusual and do require some further investigation, and they are definitely gray areas. There are many cases that you could probably accept or deny, and then litigate if necessary.”

He added: “Utilizing an index search or social media check can aid an investigation. Ultimately, an incident that appears related with no basis for denial is generally accepted with the focus shifting to treatment and return to work efforts.”