Workers’ Compensation Benefits: Who’s Covered and Who’s Not

Workers’ compensation benefits are designed to provide medical benefits and disability benefits to injured workers. But not all employees, situations, and injuries qualify for workers’ comp benefits. Further, most—but not all—employers are required to carry workers’ compensation insurance by law.

If you have sustained a job-related injury, your employer may be responsible for helping you with lost wages or other accommodations. Most employers are required by law in each state to carry workers’ compensation insurance.

This pays a portion of an employee’s regular wages while recovering from a work-related injury or illness. The injured worker, or any such person, has an entitlement to benefits or help from their employer. This can include help from service providers like doctors and nurses.

Every state but Texas requires employers to maintain workers’ compensation insurance. However, these workers’ compensation laws do not cover some types of workers. Such a person might be an independent contractor or railroad worker.

It is key that you understand your rights and your employer’s responsibilities when you suffer a work-related injury. From providing medical care to compensating for your disability and paying your medical bills, these responsibilities aim to protect employees’ public health and financial stability.

However, each workers’ compensation case is unique. Depending on your state, employer, and job, you may not be eligible for workers’ compensation protections.

This article explains who is and who isn’t covered by workers’ compensation. You’ll also learn about employer responsibilities regarding work-related injuries. 

Dealing with the legal aspects of a workplace injury can be overwhelming and frustrating. While you focus on your medical care and recovery, a workers’ comp attorney can determine benefit eligibility and work to secure the assistance you need.

Is Your Injury Work-Related?

First, you must confirm if your injury qualifies as work-related. A work-related injury occurs while you are carrying out tasks related to your job or at your place of employment. This can also include occupational diseases resulting from your work environment.

Once an injury is work-related, your employer is legally required to provide you with the necessary paperwork for a workers’ compensation case. They should also provide you with their insurance carrier’s telephone number for further inquiries.

Additionally, your employer’s workers’ compensation policy may cover job-related injuries even if you disregard workplace safety rules (such as “horseplay”). State workers’ comp laws and even some states’ courts are divided on this. You must understand your state’s laws for this section.

Below are some other considerations when determining whether your injury is work-related, for purposes of workers’ compensation claims, or other actions:

• An injury during a lunch break is typically not considered work-related unless it occurs in a company cafeteria.
• Even if alcohol contributes to an injury, it may still be considered work-related if it occurred during a work event (like a holiday party).
• A preexisting condition that is worsened on the job is usually considered work-related.
• Mental conditions sustained on the job or as a result of your job may be work-related.

The employer’s responsibilities continue beyond simply filing your claim. They must also provide reasonable time off to recover from your injury. If the injury results in permanent total disability or permanent partial disability, different provisions may apply.

In such cases, the employer must provide you with a lump sum payment or ongoing compensation. This payment depends on the extent of your disability. You might also be granted temporary total disability or temporary partial disability, depending on the severity of the impairment or injury.

Workplace Injury Compensation: Who Is Covered?

Your employer’s insurance coverage should handle medical bills associated with the injury. This includes payments to healthcare providers, such as the treating physician. Costs can be for services like x-rays, medications, and other necessary medical care.

The employer is also responsible for maintaining records of all incidents. These medical records will yield findings of fact for the insurance company. They provide a basis for compensating the injured employee and reimbursements to providers.

The reimbursement amounts to providers are typically dictated by a fee schedule established by your state’s worker’s compensation board. If a dispute arises over payments of medical bills or services, your employer’s insurance carrier should step in to resolve the issue.

Every state but Texas requires employers to purchase workers’ compensation insurance. Only workers correctly classified as “employees” are covered (as opposed to independent contractors).

Also, Idaho and Wyoming do not require coverage of undocumented workers.

Arizona, California, Texas, and other states specifically include non-citizen workers in employers’ comp coverage.

Depending on your state, workers’ comp requirements may not cover certain types of work injury claims. Some examples of individuals that workers’ compensation laws may not cover include:

• Domestic workers (housekeepers, nannies, babysitters)
• Agricultural workers
• Seasonal workers
• Undocumented workers
• Subcontractors

If you are eligible for workers’ comp, you may file a claim for benefits. However, you are not entitled to sue your employer for those same injuries in court. If your employer fails to provide coverage mandated by state law, they may be subject to fines, criminal charges, and lawsuits.

When Workers’ Comp Is Not an Option

Just because you are not eligible for workers’ comp benefits does not necessarily mean your employer is not responsible for your job-related injury. For example, if you are an independent contractor, your contract may mandate arbitration for injuries and other disputes. In some rare cases, like when an injury is intentional, an employee may sue their employer for personal injury.

Other alternatives to workers’ comp coverage include the following:

• The Federal Employees’ Compensation Act covers non-military federal employees.
• The Federal Employment Liability Act (FELA) holds railroads liable for employees’ injuries if found to be negligent.
• The Merchant Marine Act (also called the Jones Act) provides seamen with protection from employer negligence.
• The Longshore and Harbor Workers’ Compensation Act (LHWCA) provides benefits for certain employees of private maritime employers.
• The Black Lung Benefits Act provides compensation for miners suffering from a mining-related disease known as “black lung”.

In some cases, workers’ compensation benefits may not be available. For example, the employer may not be subject to laws due to their size or the type of work they do. If the injury is not covered, you must check the provisions of this section in the written agreement. This written agreement can have amendments over time.

When workers’ compensation is not an option, the injured worker might have a cause of action for personal injury. In these situations, the worker, now a claimant, may need to get help from a lawyer. These cases usually require a lawyer to show enough evidence to prove that the employer was responsible for the injury.

Work-Related Injuries and Death Benefits

Sometimes, work-related injuries result in the unfortunate death of an employee. In these cases, the employer’s insurance carrier will usually provide death benefits to the deceased worker’s dependents.

This typically includes a surviving spouse or minor children. An employer subject to workers’ compensation laws sometimes must provide certain death benefits. The specifics of death benefits can be complex and may vary based on collective bargaining agreements and state laws.

Have a Work-Related Injury? Get a Legal Help

Work-related illnesses and injuries may take months or even years to show symptoms, and some must be reported under the statute of limitations. If you have suffered an injury or illness and believe it may be work-related, first get immediate medical attention. Then, consider getting legal help.

It is not always simple to determine whether an injury is work-related. Consulting with a legal professional specializing in workers’ compensation can guide you through the claims process.

Your employer must report your injury to their insurance company within a certain number of working days from the time of the injury. They are also required to give written notice of the workers’ compensation process. In turn, you must report the injury within the statute of limitations and seek medical treatment for your impairment.

There are several ways an attorney can support you and advocate for your rights after a workplace accident:

• Handle disputes over the injury or compensation
• Troubleshoot any difficulties receiving payment or compensation for your injury
• Deal with your employer’s insurance carrier
• Help you and your dependents get paid for medical expenses and ongoing medical treatment 

FindLaw’s directory of workers’ comp attorneys can get you started. Select your state or city to review contact and ratings information for local experts. Many law offices offer free case evaluations.