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If you’ve been injured at work, then you will need to prove that you have a compensable injury in order to receive worker’s compensation benefits. So, what is a compensable injury exactly?
The most basic compensatory injury meaning is that it describes harm experienced by an employee that arose during the course and scope of their employment.
In other words, a compensable injury happens when an employee is at work doing work-related things. A non-compensable injury might happen at work but falls outside of those terms. Sound confusing? Let’s dive into more details below.
Compensable Injury Criteria
Compensable injuries happen when an employee suffers an injury, illness, or develops a condition that arises out of the course and scope of employment.
There are several situations that could result in a work-related injury that is not compensable. For instance, if the injury acted outside of the scope of employment, such as an employee deciding to do a backflip to entertain coworkers, then that likely won’t qualify as compensable. Similarly, if the injury happened outside of the course of employment, like when the person was at home cooking, then it won’t be compensable.
When is an Injury Work-Related?
An employee injury is only considered a work-related injury when it meets both of the following criteria:
- It occurred out of the course of their employment.
- It happened within the scope of their employment.
To arise out of the course of employment typically means that there is a direct connection between your work duties and the injuries. The injury must be a function of the timing and location of the work duties, meaning the injury or condition came about while the employee was on-site working or while the worker was performing work duties for the employer. Occupational diseases are a good example of a compensable injury that happens as a result of work duties accumulating over time. Repetitive trauma injuries also happen over time as a result of doing work-related tasks repeatedly.
The scope of employment means that the worker must have been acting within the reasonable scope of behavior expected and asked of them.
Employment Course and Injury Claims
Under the current compensation laws, workers who suffer a compensable injury can ask their employer to file a worker’s compensation insurance claim on their behalf. This claim can help the employee receive financial benefits to cover medical bills and lost wages while the employee recovers.
A compensable claim is a no-fault system, so employees can receive benefits even if they contributed to the incident.
Your injury claim can become complicated if the insurance company challenges the case. Some of the most commonly contested claims include lunch injuries, occupational conditions developed over time, ingress and egress injuries, parking lot injuries, slip and fall injuries, and injuries related to car accidents while on the job.
Typically, injuries that happen off the clock aren’t compensable, but there are exceptions. If you’re not sure about your situation, then it might be best to consult with an attorney about your circumstances.
Medical Exams for Injury Claims
If the insurance company questions your claims or the extent of your injuries, then they might request that you submit an independent medical examination. This request ensures that your healthcare provider’s diagnosis is as non-biased as possible. An IME doctor will give you an examination, provide a diagnosis, and report back to the insurance company or court as needed.
Talk to Workers’ Compensation Lawyer
Worker’s Compensation Insurance claims, in theory, should be straightforward, especially since the whole system isn’t dependent on whose fault the accident was. Despite that, your case can become very complicated quickly, especially if the insurance company wants to deny your claim, challenge your evidence, or pay you less than what you deserve.
Your claim could also get sticky if your employer didn’t have the right coverage or you’re struggling to get your employer to fulfill their duties and report your claim.
Certain claims will also be complex, like if you are filing a claim for occupational diseases you developed or you experienced additional distress due to the accident, like a case of medical malpractice.
In general, the more complicated your claim is, the more you need an attorney to help you.
Glossary References
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