What Injuries are Covered by Workers' Compensation?

Whether you’ve sustained a cumulative trauma or sudden injury and want to file a worker’s comp claim, you must prove that the injury or illness is within the “course and scope of your employment.” This means that the injury arose when you were engaged in an activity that benefits your employer and also occurred during the course of employment. An injury or illness is considered to be related to your work if an exposure or event in the work environment contributed to or caused it.

For example, a chef who slips and falls while preparing a meal in a restaurant kitchen would be covered. Conversely, you’re eligible for workers’ compensation if your work involves gripping and grasping that eventually results in carpal tunnel syndrome. While it can be straight forward to know that an injury will be covered if an employee is involved in an accident at work, the situation gets trickier when they were performing their job duties away from the office or when the injury or illness develops over time.

Injury at Work During a Break

Your injuries might be covered by workers’ comp if you get hurt while taking a break in your workplace’s cafeteria or break room. If you stay onsite for meal or rest break, you remain accessible to the employer and it’s also considered a benefit to the company because it saves time. If you leave your workplace and gets hurt during your break, you’ll basically not be eligible for worker’s comp benefits. For instance, an employee will likely not receive compensation for his injury if he falls and breaks his leg while walking to a nearby restaurant during his lunch break. You’d only be eligible if you were out doing something related to your work or requested by your employer. For instance, your injury may be covered if you were having lunch with a client at a restaurant or you were picking boxed lunches for a meeting.

Injury Away from the Workplace

If you’re injured offsite, your injury will be covered only if you were furthering your employers’ interests. For instance, your injury may be considered as work-related when it happens:

• While off-duty during business travel
• During professional education training
• While taking a work call in the car or working from home
• While traveling between two work sites

Injury at Work After Clocking Out

Your injury may be covered even if you have clocked out for the day, provided you were still in the workplace. For instance, you may be eligible for workers’ comp if you sustain injuries while in a parking lot owned or controlled by your employer on your way from the company. But once you leave the company’s premises and are then involved in an accident, any injuries sustained are not covered.

While worker’s comp covers most work-related injuries, there are a handful of exceptions. This means that there are instances when injuries and illnesses suffered by eligible employees are considered to fall outside the course and scope of employment.

Intoxication or Substance Abuse

Under California law, an employee is eligible to receive workers’ comp benefits even if he was at fault, except in a case where he/she has consumed an alcoholic beverage or controlled substance and the injury was directly caused by the intoxication. The California Labor Code § 3600(d) states that a work-related injury or death will not be compensable if caused by alcohol or drugs use. And while there’s no legal definition of intoxication, the courts consider it to be a situation where the individual’s faculties have been impaired through the use of intoxicants to an extent that it becomes the major or primary contributing factor of the accident. For example, a workers’ comp claim will probably be denied if an employee falls off a telephone pole because he’s been drinking.

However, there are defenses for denied claims based on intoxication-related injuries. Failing a drug or alcohol test doesn’t automatically mean that an individual is ineligible for benefits. A delayed test may not prove that the injured employee was intoxicated at the time of the accident. Conversely, if, for instance, another worker strikes you from behind with truck, your injuries may be covered even if you were intoxicated. Intoxication defenses can be difficult to prove since they involve a detailed factual and legal analysis. It’s therefore important to work with a Los Angeles Workers’ Compensation Attorney who can prove that your intoxication was not the proximate cause of your injuries.

Company Social Events

Most workplaces offer recreational and team building opportunities for their employees. Injuries that occur at company social events, such happy hour, corporate picnics, holiday parties, or baseball games might not be covered by workers' compensation. However, an injury may be covered if:

• The employer benefited from the worker’s attendance,
• It was mandatory for the employee to attend the event or the employee had a reasonable belief that the attendance was mandatory, or
• The activity occurred during business hours and on the employer’s premises.

The injury will typically not be covered by worker’s comp if the event is voluntary and meant to only benefit the employee. Whether or not an injury that occurred at a company social event will be based on the facts of the events and how the injury came about.

Workplace Horseplay and Fighting

Injuries related to horseplay and practical jokes are not covered by workers’ comp because such activities do not fall within the scope of employment. However, your injuries may still be covered if your employer tolerated ongoing horseplay. Also, you’ll probably be eligible for workers’ compensation benefits if your injury resulted from another workers’ horseplay. For example, Andrew and Daisy share the same office and have become close friends who usually make jokes. One morning, in the course of their jokes, they wrestle and Andrew dislocated Daisy’s shoulder. Under workers’ comp laws, this is considered horseplay because the activity was not related to their job duties.

Most injuries caused by altercations or fights at the workplace are not covered by workers’ comp. This issue can get blurry and usually depends on the events that led to the fight. For instance, your injury may be covered if the fight is over a work-related matter. For example, if you get into a fight with a coworker after you complain about his/her poor job performance, it’s probably a covered injury. But, if your colleague hits you after a discussion about sports goes bad, you may not be eligible for benefits.

Commuting to and From Work

Travel to and from the company or fixed workplace is not considered within the course and scope of your employment. This means that your injuries will not be covered by worker’s comp if you get injured while commuting to and from work. For instance, if you’re on your way to work and get hit by a car while crossing the road, you’ll not be eligible for benefits. But if you drive a company car and get involved in an accident while running a work errand, your injuries will probably be covered by workers’ compensation. You may also be eligible if you don’t have a fixed work site. For example, a salesperson whose work involves a lot of travel may be eligible for workers’ comp benefits if he/she gets injured while driving from home to meet a client.

Physical Injuries

Common physical injuries that prompt workers’ comp benefits include:

Back injuries, head injuries, neck injuries, knee injuries, hip injuries, eye injuries, hand and wrist injuries, shoulder injuries, burn injuries, ankle and foot injuries, loss of limb and amputation, and many more.

Repetitive Motion and Overuse Injuries

Studies show that about 20 percent of reported work-related injuries are not caused by accidents, but rather from performing the same physical tasks over and over. Repetitive strain or stress injuries only occur as a result of clicking a computer mouse or typing all day. Employees in a wide range of industries, from graphic designers and coders to home health aides and factory workers who perform the same motions consistently can develop these types of injuries. Repetitive motion injuries also go by different names such as Cumulative Trauma disorders (CTDs), Repeated Motion Injuries (RMIs), and Repetitive Stress Injuries (RSIs).

Repetitive motions or overuse causes cumulative trauma, which can put a strain on certain muscles, bones, or tendons in your body. The injuries can be extremely painful and debilitating. Examples of repetitive strain or stress injuries include:

• Back pain/strain from repetitive bending, lifting, or hunching
• Tendonitis, usually in the knee or elbow
• Vibration injuries in hands and fingers
• Carpal tunnel syndrome in the hands, wrists, and forearms
• Shoulder injuries
• Bursitis

In essence, the likelihood of developing repetitive motion injuries over time increases when certain parts of the body do a certain motion repetitively. Without medical treatment and care, the injuries can worsen and cause chronic pain, nerve damage, or even loss of motion.

Work-related repetitive stress injuries are covered by workers’ compensation. However, an employee must show that he/she was injured while working. And because these injuries develop over time and may require lengthy recovery if surgery is a primary treatment option, employers and insurance companies may challenge the claim. A seasoned Workers’ Compensation Attorney in Los Angeles can help you file a claim and represent you against your employer and their insurance company if they deny your repetitive stress injury claim.

Stress-Related Injuries

Unlike in some other states, California’s workers’ compensation system covers “psychiatric injuries.” The medical profession has found a connection between stress and a wide range of illnesses that are caused by long-term exposure in the work environment. Post-traumatic stress disorders, depression, anxiety, and other similar stress-related psychological conditions may be covered by workers’ comp if they resulted from stressful conditions at work. Emotional injuries may leave employees unable to perform certain tasks and for this reason, the employee may be forced to take time off work. For instance, if an employee is subjected to threats at work or is overworked to the point of exhaustion and consequently suffers a mental breakdown, the condition might qualify as a psychiatric injury.

Under California workers’ compensation system, psychiatric injuries are treated differently than physical injuries, and for some reasons. To begin with, psychological injuries are based on the feelings and thoughts of an employee. There aren’t good objective tests to measure internal experiences like x-rays. MRI scans, and blood tests that reveal physical injuries or illnesses. This means that it’s hard for physicians to verify claims of psychiatric injury. Second, there are many factors that may cause psychological conditions, and some may be personal without any connection to a person’s employment. Employers and their insurance companies routinely deny claims for psychiatric injuries. This means that you’ll probably jump through additional hoops to show the connection between your injury or illness and your work.

Under California Labor Code § 3208.3, employees must show that at least 51 percent of their psychiatric injury was caused by their working conditions. In order to receive workers’ comp benefits for a psychiatric injury, you must meet all of the following requirements:

• You must have a mental disorder that causes disability or need for medical treatment and has been diagnosed under accepted procedures stipulated under paragraph (4) of subdivision (j) of Section 139.2.
• You must have been employed by that employer for at least 6 months (need not to be continuous) unless a sudden and extraordinary condition at work was the direct cause of the psychiatric injury.
• If the injury resulted from being a victim of violence or you were directly exposed to a significant violent act, you must provide evidence to prove that the injury was predominantly caused by actual events of employment. This means that when all probable sources of the psychiatric injury are combined, the working conditions were at least 35 to 40 percent responsible.

In the last requirement, you basically have to show that your emotional or psychological condition wasn’t mainly caused by personal struggles in your life. As such, when you file a claim, your private life will be scrutinized digging for anything else that might have caused the condition, including a history of mental illness, criminal history, family or financial troubles, past or current drug use, and other sensitive issues.

Occupational Illness

Workers’ compensation insurance also covers medical conditions that have developed as a result of on-the-job exposure. Also, there must be a strong connection between the illness or disease and exposure. Occupational illnesses can range from traditional work-related illnesses such asbestosis/mesothelioma caused by exposure to asbestos, HIV/AIDS contracted when a health worker accidentally gets a needle stick, and hearing loss from prolonged exposure to excessive workplace noise. Other conditions like asthma may be due to exposure to the hazardous substance. Allergies may occur as a result of allergens in the workplace. Black lung disease may occur due to exposure to coal dust. Tennis elbow may occur as a result of repetitive motions of the arm and using the arms above the shoulder repetitively.

It may be relatively easy to prove occupational illness and get compensation if the condition is considered an industrial injury. This means that the condition falls under the category of occupational diseases, where there’s an established medical link between the illness and the work condition, and also there’s a low probability for exposure from work. Proving the work connection can be complicated if the illness is recognized as an ordinary disease of life. However, this doesn’t mean that it’s not always possible to get workers’ compensation benefits for lung cancer, high blood pressure, heart disease, and other common illnesses. An employee must have a preponderance of medical evidence to prove that the illness was caused by workplace exposure.

Pre-Existing Conditions

You can also be eligible for workers’ comp benefits even if you had a pre-existing condition. For example, if you suffer a back injury from heavy lifting at work, then x-rays show that you degenerative arthritis in the lower back, the new injury may be covered because it “lit up” or aggravated the old injury. Whether the condition is considered “new” under the law will determine whether or not your injury will be covered by workers’ comp. Also, the condition will be considered an aggravation provided that there’s an increased risk of disability or need to change the existing course of treatment. The aggravation would be covered.

However, a condition is not considered a new injury if symptoms reoccur or “flare-up.” Therefore, if you’re still able to work and new medical attention is not needed, the injury to the area already affected by a pre-existing condition will be recognized as an exacerbation. Workers’ comp will not cover this type of injury.

If the pre-existing condition has been aggravated, your employer will only pay for the portion of your injuries that have been caused by the recent accident. This means that the amount of benefits you may be entitled to may be reduced by the percentage of your injury that can be attributed to other factors. And if your doctor finds that the aggravation of your pre-existing condition is not treatable, you may be entitled to permanent disability benefits.

Psychiatric Injury Resulting from Work-Related Physical Injuries

Employees may develop mental or emotional conditions after suffering a work-related physical injury. Typically, physical injuries and disabilities cause pain, isolation, and life changes. They also often lead to anxiety, depression, and sleep disorders. The rules, in this case, are different and typically more liberal. The psychiatric conditions are considered a “compensable consequence” of the work-related physical injury and this means that the employee should be entitled to benefits.

Death Caused by Work Injury or Illness

In the event of death due to injuries caused by a workplace injury, illness, or accident, the eligible dependents collect workers’ comp death benefits. Close members of the deceased worker’s family that can collect benefits include a spouse, children, and other family members who totally depended on the worker for financial support and care. Those who qualify as dependents are entitled to death benefits and burial expenses.

At Workers Compensation Attorney Law Firm, we care about our clients. We understand that employees who’ve been injured at work need relief from the very stressful and overwhelming situation. While the relief lies in California’s workers’ compensation system, you must deal with your employer and the insurance company in order to receive benefits you need to obtain medical care and to provide you with financial security while you recover. The rules can be very complicated, especially to an individual who is already dealing with the financial, emotional, and physical trauma that a work-related injury can bring. What’s more, you could run into trouble if you choose to file a claim without the help of an experienced workers’ comp attorney.

The lawyers at Workers Compensation Attorney Law Firm can analyze your case, determine whether there’s a likelihood for your illness or injury to be covered, explain the California workers’ comp claims process, explain the time limit for filing claims, and help develop the evidence needed to support your claim. We’re zealous advocates who will stop at nothing to ensure that you get the compensation you’re entitled to under the law. Let us use our skills and experience to steer your claim to a successful conclusion.

If you have any question or concern, contact our Los Angeles workers compensation attorney at 310-956-4277 or fill out our online contact form.