If you get hurt at work, is it automatically a workplace injury? The short answer is no. Whether an injury is covered by a workers compensation policy – or “compensable” – depends on many factors.
What makes an injury compensable, and what should employers and employees expect when filing a work comp claim?
The basics of workers compensation insurance
The purpose of a work comp policy is to protect the employer and the employee in the case of a workplace injury. It covers the expenses associated with the injury without assigning fault to either party. In general, for employees with compensable injuries, the insurance provider pays for 100% of medical expenses. It also often pays for two-thirds of the employee’s average weekly wage if the injury causes them to miss work.
Who needs a work comp policy?
Work comp requirements vary by state. In Missouri, businesses with five or more employees – or contractors with one employee – must have a work comp policy. This includes corporate officers. LLC members may elect to exclude themselves.
If your state’s laws require your business to have work comp coverage and you don’t, you may be responsible for injury expenses as well as fines in case of an employee injury. Talk to your agent or contact a work comp insurance provider if you’re unsure whether you need a policy.
Workplace injuries covered by work comp
According to Missouri work comp law, an employer’s policy covers “personal injury or death of the employee by accident or occupational disease arising out of and in the course of the employee’s employment.”
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The law defines an accident as an unexpected or unusual event caused by something specific during a single work shift.
A work-related activity must be the prevailing factor causing the medical condition and disability. If an employee experiences an injury at work that’s unrelated to their job, work comp likely won’t cover it.
Likewise, if work simply triggered the injury but was not the primary cause, it may not be covered. Work comp also may not apply if the employee would’ve been equally exposed to the risk in everyday life.
Work comp also covers occupational diseases under the same circumstances as injuries. On-the-job exposure must be the prevailing factor to contraction of the disease. In general, it usually doesn’t cover ordinary “diseases of life” such as natural hearing loss and cardiovascular disease. Work comp may cover mental injuries resulting from work-related stress if the stress is extraordinary and unusual in nature.
Examples of compensable injuries and illness
While the law provides guidance about which injuries and illness work comp covers, it can be tricky to translate that into the real world. Here are a few examples that would likely be covered – and some that wouldn’t be.
Injuries that would likely be compensable
- Musculoskeletal injury from lifting: Overexertion is one of the most common causes of workplace injuries. If lifting objects is part of an employee’s job and they injure their back, your work comp policy would likely cover the costs associated with the injury.
- Slip on a wet floor: Do you post “slippery when wet” signs in your workplace? This type of signage can help prevent employee slips, which are usually compensable.
- Spider bite: Unless your job is working with wildlife, work comp is unlikely to cover this type of injury.
- Old softball shoulder injury: If heavy lifting exacerbates an existing non-work-related injury, work comp may not cover it, even if lifting is part of the employee’s job.
Illness that would likely be compensable
- Asbestosis: Working in some environments can expose employees to harmful materials like asbestos. The link between the employee’s job and the resulting medical condition is often clear. In these cases, work comp will usually cover the illness.
- Heart attack not caused by incident at work: Many people spend at least one-third of their day at work. It’s inevitable that some individuals with conditions such as deteriorating cardiovascular health will have related incidents while at work. Even if it happens at work, it won’t be covered by work comp unless the work caused it.
Role of penalties and your safety program
In some cases, an injured worker’s work comp benefits can be reduced or denied if the employer shows that the employee was willingly violating a company policy, such as drug-free workplace or personal protective equipment policies. However, to assess a penalty the employer must be able to show that the employee knew about the policy.
This is one reason why safety documentation is so important. Documented safety policies not only prevent workplace injuries, but also help you save on claim costs when an employee blatantly ignores the rules. Penalties typically reduce the employee’s compensation by 25-50%. They can only be applied if the safety violation was the cause of the incident that led to injury.
Every work comp claim is different
If you’ve seen one work comp claim – you’ve seen one work comp claim. Evaluating the compensability of an injury can be a complex job requiring investigation and expertise. While the information above helps paint a picture of which injuries work comp covers and which it doesn’t, remember that your insurance provider evaluates each claim on a case-by-case basis.
For this reason, it’s important to report a workplace injury as soon as you know about it. The earlier you file the claim, the more complete information your claims expert will be able to collect from you, the injured worker and any witnesses.
Your insurance provider wants the same things you want – to understand exactly how an injury happened, make sure it doesn’t happen again, and get the injured worker the care they need. By working with your provider’s representatives and keeping open communication with your employees, you’ll be set up to successfully manage any work comp claim.