Factors That Determine Workers' Compensation Eligibility

Those who sustain job-related injuries can usually claim workers’ compensation benefits. Imagine a worker gets hurt at work or gets sick from doing their job over time. This injured worker can file a workers’ compensation claim. This means they ask for help to pay for things like their medical bills, medical care, or money they lost by being unable to work. The rules for this system are a part of workers’ compensation law.

But you must be eligible for workers’ compensation to collect benefits. Eligibility is determined by your status as an employee. It is also dependent on whether the injury was work-related. Depending on state law, the size of your employer can also impact your eligibility.

This article outlines the factors that determine workers’ compensation eligibility:

• Employment classification
• Injury circumstances
• Employer insurance requirements

Keep in mind that eligibility requirements vary by state. A workers’ comp attorney near you can review your situation, determine your eligibility, and recommend next steps.

Are You Classified as an Employee?

Not all workers can make a workers’ compensation claim. For example, you likely aren’t covered if you are an independent contractor, like a freelancer, consultant, or volunteer. The law mainly protects employees. This includes full-time and part-time employees.

First, you must determine if you are an employee under the law. You are eligible for workers’ comp benefits if you are an employee. Independent contractors often must (through contract) use arbitration for disputes. This includes injury claims.

If you have been injured at work and believe you are misclassified as an independent contractor, you should talk to an attorney immediately. 

Are You Exempt From Workers’ Comp Benefits?

Workers’ compensation law does not cover some jobs. Some farm workers, casual or seasonal workers, and people working at home may not be protected. Federal law covers federal employees, not state law. If you are unsure, you should check with the Department of Labor in your state.

Even if the employer disputes the facts of your claim, your workers’ compensation eligibility may be denied. The most common categories exempt from workers’ compensation requirements under state laws include:

• Undocumented workers
• Seasonal workers (such as migrant farm workers)
• Domestic workers, including nannies and caretakers
• Agriculture workers

Suppose you work for a temp or staffing agency that leases you to another employer. The agency may be responsible for workers’ compensation coverage in that case. This is instead of the company where the product is being made.

Is Your Employer Required to Carry Workers’ Comp Insurance?

Most employers must carry workers’ compensation insurance. This insurance comes from an insurance company. In some cases, employers are self-insured. That means they pay for workers’ compensation cases out of their pockets.

State laws determine whether an employer must carry workers’ compensation insurance. This depends on the:

• Number of employees
• Type of business
• Work being performed

Most states require employers with at least one employee to carry insurance. Some states exempt small businesses with fewer than three employees. But remember that some employers buy workers’ comp insurance even if they are not required to since it helps protect them from lawsuits. If an employer does not have this insurance, they may be breaking the law.

Is the Injury Work-Related?

Workers’ compensation is only for job-related injuries. That means the injury must have happened while you were working or because of your work. It is not always clear whether an injury related to the job is compensable under workers’ compensation eligibility rules. For an injury to be “work-related,” a causal relationship must be established between the injury and the employment relationship.

For example, if you hurt your back while lifting heavy boxes at work, that would be a work-related injury. An employee who breaks his leg during an official company retreat at a ski resort could claim it was work-related. But injuries that occur during the morning commute, for instance, are not covered.

Are You Eligible for Other Benefits than Workers’ Comp?

Sometimes, when a worker is hurt, they can file a personal injury claim or a personal injury lawsuit. This is different from a workers’ compensation claim. For example, you might have a personal injury case if you are an injured employee because of a car accident while working. Or, if one of your co-workers intentionally hurts you, you could sue them.

You have other options if you are not eligible for workers’ compensation. Depending on your employment situation, you can claim compensation for work-related injuries through something other than workers’ comp. In some circumstances, including injuries intentionally inflicted in the workplace, you can sue your employer.

Other alternatives to workers’ comp include:

• Federal employees (non-military) may seek relief through the Federal Employees’ Compensation Act (FECA)
• Mariners or seamen may file claims for injuries stemming from employer negligence through the Jones Act (also called the Merchant Marine Act)
• Employees in traditional maritime occupations, such as shipbuilders and longshore workers (excluding crew members of any vessel), may be covered under the Longshore and Harbor Workers’ Compensation Act (LHWC)
• Railroad workers are compensated for workplace injuries under the authority of the Federal Employers Liability Act (FELA)
• Current and former coal miners who suffer from a mining-related injury are covered by the Black Lung Benefits Act (BLBA)

An Attorney Can Help With Your Workers’ Comp Claim

Legal help is available if you’re unsure of your workers’ compensation eligibility. An attorney can help you understand the law and what benefits you may be entitled to, such as money for medical expenses and lost earning capacity.

An attorney can also assess your situation for other benefits, including:

• Disability benefits, if you have a permanent disability or permanent impairment
• Reimbursement and premiums for insurance
• Vocational rehabilitation, which helps with job training and placement
• Death benefits, if you’re the family member of a worker who died from a workplace injury.

Under the law, the insurance carrier or the self-insured employer must pay these benefits to eligible workers. Your worker can assert your rights to these benefits. They can also help if the insurance carrier or your employer is challenging your claim.

FindLaw’s directory of workers’ compensation lawyers can connect you with qualified legal help near you. Select your state or city to review contact and ratings information for local experts. Many law offices offer free case evaluations.