Do You Qualify For Workers’ Compensation Benefits?
Workers compensation insurance requirements and coverage are based on the type of industry, number of employees and entity organization. Read important WC requirements.
Three broad requirements are involved in determining if you are able to file a workers’ compensation claim:
- Your employer is providing workers’ compensation insurance.
- You are an employee of that business.
- The accident or illness you suffered must be related to your work.
First Requirement—Your Employer has Workers’ Compensation Insurance
The first requirement is that you can only collect workers’ compensation if your employer provides this coverage. The laws requiring an employer to have such coverage are very broad; however some variations exist between states.
A number of details may give an employer an exception from providing such insurance. These items may include the total number of employees, the yearly gross payroll, the type of work the employees are engaged in, or the type of business.
Classes of workers that might not fall under the mandatory coverage are performers, musicians, crop dusting employees, or real estate brokers. Churches and nonprofit organizations could also be excluded from being required to provide this coverage, but this is uncommon.
Seasonal workers most likely would not be covered. If you’re an undocumented worker, however, it could depend on where you work. States with a high number of such workers, for example, California and Arizona, are more likely to require such coverage, while workers in northern states, such as Wyoming, which does not have many such workers, are not covered.
There is some variation of state laws in this regard. For instance, Idaho requires that every employer with at least one employee provides this insurance, however, Missouri requires a company to have at least five employees before workers’ comp coverage is mandatory.
Some states allow an employer to purchase workers’ comp coverage even though the law specifically exempts them. The advantage to the company is that their workers are protected in case of an accident in the workplace and that the workers give up their right to sue if they accepted those benefits. In this way, the employee and the business are protected.
A tip here is that if your employer says their company is not required to provide workers’ compensation insurance to you, double-check with the workers’ compensation board or a professional not associated with your employer or the company. This could be someone such as an attorney who specializes in these types of cases.
Second Requirement—You Must be an Employee
The second requirement is that you are an employee of that company or business.
You are likely covered if you are working for just one employer, working on a regular schedule, and receiving a regular wage. The law usually requires employers to subscribe to that coverage. They do not have a choice in the matter. Every state has a workers’ compensation system in place. Exceptions exist for certain businesses, but applicable definitions are not always completely clear.
Actual eligibility rules vary from state to state, but a common theme is that the employee must be under the control and direction of the employer. There are some workers who are exempt, for example, independent contractors would not be covered. A tradesperson hired for one particular job and has control of their own tools and workspace would not be covered either.
Domestic worker is another class that is often exempt. If you would hire an individual person to be your maid, the workers’ comp rules could be different compared to hiring a company to do that work. In California, you are required to provide for the workers’ compensation coverage if you are the employer, but in Rhode Island, that type of worker may be excluded. In addition, it could depend on how many hours per week they work, such as in Massachusetts where a minimum of 16 hours work is required per week before coverage is mandated.
The terms “independent contractor” and “tradesperson” also have some gray areas. In fact, one method that employers are known to use to avoid workers’ compensation insurance costs is to have workers sign a form stating that they are independent contractors. This allows the employers to claim they have no responsibility to provide for that coverage.
Even if you signed such a form and it can be established that the employer still exerted control and direction over you, a claim could still be accepted by workers’ comp. This is a more complicated situation, and you should bring in a specialized attorney to analyze such a particular case to receive a fair evaluation.
Other common exceptions under workers’ compensation are owners or partners in a business, some (but not all) agricultural workers, and unpaid volunteers.
If your claim was denied because of one of these exceptions or because your employer says you are an independent contractor, you should seek the advice of an attorney who is well versed in this field. Do not take your employer’s word on anything this important. An additional option available to you if you suffer from a work injury and are not covered by workers’ comp is the right to sue your employer in a civil court.
Third Requirement—Work-Related Injury
The third and last requirement for being covered under a workers’ compensation program is that the injury, illness, disability or disease must relate to the work.
Many people think of accidents as being the sole cause of a workers’ comp claim, but there are others. Occupational diseases could be covered, as well as a sickness that develops from exposure to chemicals. An example of chemical exposure could be working near paint fumes with no safety equipment provided, inadequate safety training, or defective safety equipment.
Injuries that simply make an existing condition worse are also often covered. In addition, injuries that become a more serious problem over time can be covered. A good example would be carpal tunnel syndrome, where a repetitive movement aggravates a person’s wrist structure. This condition may be referred to as a repetitive stress injury or a cumulative trauma disorder and is a common injury that results from typing every day.
A different problem might come from heavy lifting or moving heavy equipment or supplies and could cause significant medical issues to knees and backs.
Many occupational injuries and diseases are covered throughout the United States. Normally, if you are injured in the scope and course of your employment and require medical attention beyond simple first aid, your injury would be covered.
These occupational diseases are illnesses that have been determined to occur more frequently in certain groups of workers as compared with the general population. Occupational cancer is one such example for workers involved in asbestos removal. Another would be optical diseases caused by repeated exposure to visible, ultraviolet, or infrared light, such as a laser.
The most common examples are lung diseases, such as black lung disease or silicosis, if you labor in mines or quarries. Others would include skin problems that develop if your hands are kept wet in chemicals for a long period of time while working. Dermatitis and eczema are common examples, but even sunburn could be considered if you were required to work outside in the sun for long periods of time.
A 21st-century example that is becoming more common is Computer Vision Syndrome, (CVS), which applies if you are working with information technology on a computer for hours on end. This is not just one medical issue but many. Because so many workers are required to work by staring at a computer screen for hours and hours, eye problems can develop, such as eye strain and pain. This is similar to repetitive motion injuries like carpal tunnel syndrome. CVS comes about because your eyes are tracing the same path back and forth across the computer screen. In addition, you may have to look down to read papers and then look back up to the screen. This can cause significant fatigue with the eye muscles.
Additional examples of injuries that could be covered by workers’ compensation are long exposure to a high level of noise resulting in a hearing loss which could be an occupational disease. A deciding factor for these types of injuries would be if they occurred primarily in the workplace and not from a hobby or home activity. If the workplace situation applies, they would be covered.
If you suffer an injury going to or returning from lunch, it will probably not be covered unless your employer offers a cafeteria service, such as in a hospital. A cafeteria would benefit you because of its convenience and would help the employer keep you at the workplace, allowing more time to work. Another example would be if you were injured while driving as a requirement of your job. This could occur if a manager was required to visit different work sites or if a salesman needed to call on customers. Such an injury would likely be covered.
Preexisting conditions may also be covered depending on the circumstances. For instance, if you previously suffered from some arthritis in your hands and were able to function with no problems, but after years of having to fill out pages of work forms by hand, it started to cripple your fingers. This example would probably be covered by workers’ comp.
Psychological and Stress Issues
Keep in mind that psychological and stress problems might be caused by an original occupational injury. It substantiates your workers’ comp claim if a link can be shown between the injury and the illness. You may need a baseline to show how the condition has progressed over time.
Stress-related problems would also most likely be covered if they resulted from a single high-stress incident and not from a claim that stress built up over a long period of time. An example of this might be if you were a police officer and responded to an unusually horrific crime scene and began developing PTSD (Post Traumatic Stress Disorder) symptoms.
If you suffered from depression from a previous injury that was work-related, it may be covered because the original injury occurred while on the job, and the depression was an outgrowth of that condition. These types of cases are usually denied, however, so it would be wise to have qualified legal assistance to provide the best possible chance of approval. The stronger the link between an incident and PTSD or between a work injury and depression, the better the chance of having benefits awarded. Having an attorney experienced in such matters will increase the likelihood of a successful conclusion.
Whether or not the injury is covered could vary from state to state. Remember that accepted coverage in these unusual cases could be determined by a previous court decision in that particular state. If in doubt, locate a highly qualified specialized attorney to evaluate your case. This person will be able to properly research case law and previous decisions in your state to evaluate the chances of approval.
Other claims that have been decided from court cases in the past may vary widely between localities. For example, depending on particular job requirements, an injury sustained during a commute to or from a work location could or might not be covered. Or, an acceptable workers’ comp claim could result if an accident occurred when you had to change work locations during the day.
Many cases are not so clear-cut. What if you were driving your own car to run an errand for your boss after normal work hours and were involved in an accident? A normal drive to or from work would probably not fall under workers’ comp, but it probably would be if you were driving a company vehicle.
What if you fell from a stage during a skit at a company team-building meeting and broke your arm? Many times workers’ comp would cover the incident even with voluntary alcohol consumption by the injured employee.
These last examples show a definite tie to work but were not strictly speaking work related and could be decided either way. The best way to ensure a favorable decision from the workers’ comp board is to hire a skilled attorney specializing in workers’ compensation.