Are All Workers Injuries Compensable?

Workers Comp 101Here's a checklist to help you determine if injuries are covered by workers comp.

Injuries must meet five criteria to be covered:

It's broken down like this:

  1. If the injured person is your employee, and…
  2. The employee has suffered an illness or injury
  3. Which occurred in the course of employment
  4. And arose out of the circumstances of employment
  5. That resulted in an impairment and/or…
  6. Resulted in lost wages, then…
  7. The injury is considered work-related and is covered by employers workers' comp program.

Determining Compensability

Here is where you determine whether your employee's injury must be compensated by workers' comp.

Just because an injury occurred at work does not mean an employee is automatically entitled to workers' compensation.

However, because workers' compensation is a "no fault" system an employee is entitled to coverage even if it is his/her fault.

You have to distinguish between checklist items 3 and 4.

Just because someone gets injured AT work, doesn't mean that injury came from doing the actual work.

  • For example, horseplay could be involved, potentially excluding the injury under the workers comp laws of that state

    Under these type of circumstances you would not be obligated to compensate that employee for the injury

  • Or, if an employee has a heart attack at work:
    • The injury does not necessarily arise out of the circumstances of employment.
    • If the heart attack is caused by a personal condition rather than a work condition then he/she may not be entitled to workers comp
    • But if the heart attack occurred at work due to a very heavy workload, the injury might be considered arising out of employment, and therefore eligible for workers' comp benefits
  • Ask legal counsel and the adjuster to review the case when the causes are not clear. These decisions often depend on the interpretation of state laws and prior legal cases.
  • Perform a compensability investigation as soon as the claim is reported. Small claims turn into large claims, so document the claim defensively from the first day.

How does a Compensability Investigation Differ from an Accident Investigation?

A compensability investigation determines claim viability at the onset of the claim. You are determining if the injury is one you must compensate him/her for by going through steps 1-6.

This differs from an accident investigation which is done to determine how the incident occurred. An accident investigation can be included in a compensability investigation; however, a compensability investigation might also include:

  • A review of the injured person's employment status
  • A review of his/her prior injuries and illnesses to determine if the current condition arose from the workplace
  • An investigation to determine if there are other medical reasons for the current symptoms

Can an Employee Sue Your Company if They Receive Workers' Compensation?

Workers' Compensation was intended to be the 'sole remedy' for an ccupational injury; therefore, an employee cannot usually sue an employer once they have received workers' compensation payments.

Technically, the employee is "barred" from filing a civil suit against the employer, but there are exceptions. Check with your legal counsel if you believe an employee will file a law suit against the company.

Next Topic: Managing The Process

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