What Is and Isn’t Covered by Workers’ Comp?

People often have a lot of workers’ compensation questions, how it works, and what it covers and doesn’t cover. 

For example, can you get workers’ compensation for pain and suffering? We’ll tackle questions like these below and discuss what’s covered and not covered by workers’ compensation. 

What is Workers’ Compensation?

Workers’ compensation or workers’ comp provides wage and medical benefits for people who get sick or hurt at work. Each state mandates the coverage, and the benefits vary depending on the state as a result. It’s considered social insurance, and business owners are protected from civil liability if their employees get hurt at work. 

There are limitations to the benefits of workers’ comp for both employers and employees though 

All states, with a few exceptions, require businesses with non-owner employees to purchase workers’ compensation for those employees. If a business is required to have workers’ comp coverage and they don’t, it can lead to expensive consequences. 

Workers’ comp will provide medical expenses, rehabilitation costs, and lost wages to employees who become ill or get injured in the course and scope of their job. The coverage will also pay death benefits to families if an employee is killed on the job. 

How It Works

An employee doesn’t have to be on work property to get coverage—they do have to be acting within the scope of their employment. For example, if someone is making a work delivery and they get into a car accident, this could make them eligible for coverage from workers’ comp. 

Once a claim is filed and processed, the sick or injured employee can be paid if the employer and the insurance company agree it’s a work-related injury or illness. If an employer doesn’t think the illness or injury was caused by work, then the claim can be disputed. 

If an employee is hurt or becomes ill, they have to report it to their employer in a timely way to be eligible for benefits. 

Once they report their illness or injury, the employee will get the required paperwork and forms from their employer. When an employee returns the completed paperwork, the employer files the claim with the insurance company. The employer may also have to notify the state agency or board about the illness or injury. 

Depending on what the outcome is, an employee may appeal it. 

What Does Workers’ Comp Cover?

Worker’s compensation provides coverage for the following:

• Medical expenses: This type of insurance should cover the costs of immediate care related to a workplace accident. For example, if you have to go to the emergency room or take an ambulance ride, the insurance should cover these expenses. Other medical care, including surgeries, hospital stays, medicine, and rehabilitation, is also likely to be covered by workers’ compensation. 
• Disability benefits: If someone is seriously hurt doing their job and they can’t return for days or even months, workers’ compensation benefits should cover part of their lost wages during their recovery. 
• Fatal injuries: If a situation at work is fatal, then death benefits may be paid to surviving family members to cover the costs of the funeral and to provide support to the family members. 
• Liability insurance: Workers’ compensation insurance might include liability insurance for the employer, protecting them from lawsuits related to work injuries. If a worker, as an example, claims that a lack of basic safety in the workplace led to their injury and they sue their employer, coverage might pay for attorney’s fees, court costs, and judgments or settlements. 

What Workers’ Comp Doesn’t Cover

The things that workers’ compensation generally doesn’t cover include:

• Injuries from drugs or being intoxicated
• An injury someone claims after they’re laid off or fired
• Injuries from violating company policies
• Wages for replacement workers
• OSHA fines
• Injuries sustained by independent contractors

Some of the specific examples of things not covered include:

• A common one-time illness like the flu
• Ordinary diseases of life
• Conditions existing before an employee was hired or started doing a certain job
• Employee horseplay that causes an injury
• Heart attacks
• Injuries stemming from a fight that an employee starts
• Injuries that occur because of participation in off-duty recreational activities
• Something that occurs when an employee’s behavior violates company policy
• An injury that occurs when an employee is committing a crime
• Injuries that can be treated with simple first aid 
• An accident occurs out of an “act of God.”

To go back to our original question above, you can’t get workers’ compensation for pain and suffering. You can, however, get these benefits for psychological symptoms related to conditions like PTSD. If you want to seek damages for pain and suffering, you have to file a personal injury lawsuit. 

The big objective of workers’ compensation is to keep courts from being clogged up by injuries related to work and to make sure workers get expedited compensation for injuries. There is a tradeoff because employees can get compensation without proving fault, but the downside is the inability to win non-economic damages, including not only pain and suffering but emotional distress, loss of enjoyment of life, and mental anguish. 

In certain circumstances, you could be able to file a personal injury lawsuit.  One is if your employer intentionally hurts you by deliberately ignoring safety issues or physically assaulting you, for example. 

If you’re an independent contractor rather than an employee, then you aren’t eligible for workers’ compensation, but you are potentially able to file a personal injury lawsuit. 

If your workplace accident is the fault of a third party, you may also be able to file a personal injury lawsuit. In these cases, it’s a good idea to work with an experienced personal injury attorney when exploring your workers’ compensation questions because it can be challenging to calculate pain and suffering damages. 

Again, it’s important to emphasize that every state has its own set of laws as far as workers’ compensation goes, so while most are similar, you may see some differences in specific issues depending on where you live.