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Claims and Individuals That are NOT Covered by Workers’ Compensation

Gerry Dumke
Posted on: January 31, 2020 by Gerry Dumke

Throughout the United States, employers are expected to provide safe workplaces for their employees. Workplace-related injuries can cost billions of dollars in lost productivity each year, so employers have a strong incentive to eliminate common workplace hazards. Even with numerous protections in place, injuries and illnesses still occur. Workers’ compensation insurance and similar occupational insurance plans help injured employees with financial support for medical expenses and lost wages. Unfortunately, not all claims are covered, nor are all workers, by these insurance solutions. It is critical that employers gain an understanding of the claims and individuals not covered by workers’ compensation.

Coverage Under Workers’ Comp Insurance

Under most state workers’ comp regulations, an employee injured in the course or scope of their duties may file a claim. The injury or illness does not have to occur in the workplace; remote workers or employees traveling between job sites as part of their duties may also be covered under most plans. Most workers’ comp plans are “no-fault”, with workers generally covered regardless of how or what caused the injury or illness. 

One area that many employers do not clearly understand in terms of coverage is that of occupational diseases, or those diseases resulting from exposure to hazardous chemicals or other workplace conditions. While these illnesses do not always manifest themselves within the workplace — owing to the cumulative effect of the exposure — the employee’s subsequent illness is covered. 

Worker Exclusions Under Workers’ Compensation

Workers’ comp normally provides a broad level of protection for employees injured or made ill on the job. Most states require some form of this insurance to be in place, even if a business is small and has only a few employees. There are exceptions, of course, and there may be specific employee types or classes excluded from coverage. These may include:

  • Business owners, partners, or sole proprietors — several states have provisions for these employee classes to be covered if they are willing to pay their own insurance premiums.
  • Volunteers — as they are not considered formal employees of a business or organization, coverage is typically not extended to them. Again, there are exceptions; volunteer first responders are usually covered by workers’ comp, as are volunteers of non-profits that elect to purchase workers’ comp insurance for them.
  • Independent contractors – as these individuals are not formally part of a business organization, they are often excluded from coverage. Taxi drivers are a unique worker class and are often excluded because they are typically considered independent contractors of the taxi company.
  • Federal employees, railroad employees, and commercial marine workers – although these employee classes do have some form of compensation coverage, they are not typically covered under traditional employer workers’ compensation. Most often, these classes are covered under specific federal Acts, such as the Railroad Workers Act or the Federal Employees Compensation Act.
  • Part-time domestic workers, including maids, part-time gardeners, handymen, or short-term seasonal workers. 

Injuries or Illnesses Not Covered Under Workers’ Compensation

Employees injured or becoming ill on the job are covered by workers’ compensation insurance, helping to provide financial support for medical expenses and lost wages. Just as with exclusions to certain worker classes, however, there are exclusions in coverage for certain injuries and illnesses. Common exclusions include:

  • Injuries resulting from illicit drug or alcohol use in or out of the workplace. Most workers’ comp plans have strict guidelines concerning coverage for employees under the influence of drugs or alcohol, and many plans require drug screening after an injury claim.
  • Pre-existing physical or mental health illnesses.
  • Certain other mental health conditions, such as some work-related stress disorders.
  • Injuries occurring from at-work horseplay, fighting, or violence, even if the injuries occur on employer premises.
  • Injuries or illnesses that can be successfully treated with first-aid supplies on the work premises. Such injuries are not severe enough to warrant an insurance claim. 
  • Injuries occurring during the commute to and from the workplace.
  • Injuries occurring during meals or break periods and the employee is away from employer premises. 

Employers must understand the coverages and exclusions of their workers’ compensation insurance policies. Remember that there are exceptions to exceptions, and employers with questions or concerns about claims should seek the help of their state’s workers comp agency or insurer for guidance. 

About Caitlin Morgan

Caitlin Morgan specializes in insuring assisted living facilities and nursing homes and can assist you in providing insurance and risk management services for this niche market. Give us a call to learn more about our programs at 877.226.1027.

Posted in: blog Workers Comp Workers Compensation