Workers’ compensation is also sometimes referred to as workman’s comp. This is a no-fault benefits system to help protect a worker who gets sick or hurt on the job.

When someone files a workers’ compensation claim, in general, rather than suing their employer they file a claim against their employer’s workers’ comp insurance company.

Some people do find that the claims process is confusing, and it can be difficult to know what’s covered and what isn’t, so the following are things to know.

How Does It Work?

Worker’s compensation is meant as a way to cover the cost of things like lost wages and medical bills stemming from illnesses and injuries related to work.

A business owner should have worker’s compensation insurance, and almost all states require that you have this coverage if you have employees.

As soon as you hire your first employee, most states require that you get coverage.

Texas is the only state that doesn’t require you to purchase worker’s compensation insurance.

In some states, you aren’t required to have it until you hire a certain number of employees beyond one.

There are benefits to this coverage for business owners and employees.

For example, it protects small business owners. Otherwise, you might have to pay lost wages and medical expenses out-of-pocket. Most workers’ compensation policies also include employer liability insurance, and with this benefit, judgments, legal fees and settlements are covered if an employee sues.

For employees, there’s protection stemming from the fact that an extended absence from work can be financially devastating. Employees are taken care of if they can’t work because of an illness or injury related to their work. It will cover part of the pay they miss while they’re recovering and cover medical expenses.

It’s a no-fault system, so that means that even if it’s the employee’s fault they’re injured, it should still technically pay their claim.

There are two basic eligibility requirements.

First, you have to be employed by a company that has workers’ compensation coverage or was legally supposed to have it. The second requirement is that you were injured at work or you were injured because of duties related to your job.

What’s Considered a Workplace Injury?

While the idea of workers’ compensation can seem somewhat straightforward, that’s not always the reality.

Even though workers’ compensation is not fault-based, if your injury is self-inflicted, it’s generally not covered. Stress and psychiatric disorders tend not to be covered, as are injuries caused by fighting or roughhousing. Injuries that occurred while violating company policies, under the influence of drugs or alcohol or those injuries that occur while committing a crime are also not covered.

Occupational Illnesses

While we more frequently associate worker’s compensation with injuries, it does sometimes cover diseases or illnesses that an employee develops because of work-related exposure.

Work-related sicknesses can range from cumulative illnesses due to exposure to toxins, to COVID-19 in some cases.

It can be somewhat challenging to prove a link between work and disease, though, unless it’s something that has a well-established link.

For example, if you get a common chronic illness such as a type of cancer, it can be tough to show that’s related to your job.

If you can’t go to work because you got coronavirus or you were exposed at work, sometimes you may be eligible for workers’ comp benefits while you’re in quarantine, but it depends on the laws in your state and your specific situation.

You would have to show you were exposed at work, and during a pandemic with widespread illness, that’s pretty challenging to do.

In some states, there have been measures for health care providers and first responders to make it easier for these employees to get workers’ compensation benefits during the pandemic.

For example, in Minnesota, there was a temporary law assuming some health care workers and first responders with COVID-19 contracted it while working. That law required that the insurance company prove otherwise rather than the other way around.

Injuries Covered by Workers’ Comp

While it’s not an exhaustive list, some types of injuries tend to more frequently be covered by workers’ comp than others.

For example, workers’ comp will frequently cover overuse and repetitive motion injuries, like chronic back pain and carpal tunnel syndrome.

Hearing loss is usually covered for people who work in loud environments such as in construction or manufacturing.

In some states, PTSD is covered, but only if it was caused by something sudden and very traumatic, such as a mass shooting or robbery.

What About a Pre-Existing Condition?

There are instances where you might be eligible for workers’ comp even with a pre-existing injury if your work aggravated the condition.

What’s Not Covered

Some of these were mentioned above, but there are some situations that are typically exclusions to workers’ compensation coverage.

For example, if you’re injured during your commute, then this usually won’t be considered within the scope of your employment.

If you were hurt in an accident while driving a company car or doing an errand for work, then you might be covered.

Workers’ compensation coverage probably won’t extend to any illness or injury that occurs while you’re doing recreational activities.

For example, if you’re hurt at a company field day, you may not be covered unless you were required to attend the event or your employer benefitted from you being there, in which case the injury might be.

Another example of a not-covered situation is when an employee is intoxicated or under the influence of substances and gets injured.

As an example, if you’re drinking at work and fall from a ladder, there’s a high likelihood the claim will be denied.

Workers’ compensation can seem overall straightforward, but the reality is there are different rules and exceptions depending on the state. If your insurance company says your injury isn’t covered and you believe that’s not the case, you may end up having to work with a lawyer on an appeal.