English 
Spanish In general, workers’ compensation benefits cover injuries and illnesses that occur because of work or at work, as long as they are within the course and scope of the job. When these cases go to court, the courts generally interpret “course and scope” very broadly. Most tend to side with covering most injuries suffered by hurt employees.
Still, there are some types of injuries not covered under workers’ compensation. This includes those that occur intentionally, because of horseplay, or because the worker is drinking or using drugs. If your employer or their insurer denies your claim or you run into other issues, a workers’ compensation lawyer can help.
Types of Injuries not Covered Under Workers’ Compensation
In theory, workers’ comp claims should be denied only rarely. There are relatively few exceptions to these policies, and most of them occur infrequently. However, this is not the reality for many workers. Many receive a denial or run into other concerns despite having a valid claim.
Some circumstances when your employer’s workers’ comp policy might not cover your medical bills and provide income loss benefits include:
- When you were not on the clock and not working for the employer
- When your conduct violated company policy, causing the injuries
- When you were using drugs or alcohol on the job
- When you were in the act of committing a serious crime
- When you intentionally caused the injuries
- When the injuries occurred because of workplace horseplay or fighting
- When the injuries occurred on your way to or from work
- When your injuries occurred during recreational activities, such as a softball league
- When you suffered a heart attack
- When you catch a common, one-time illness, such as a cold or flu
The insurer should weigh the merits of each case individually and examine the facts of what happened to determine whether it meets a policy exclusion. The vast majority of claims won’t meet these exclusions.
If the insurer says your injuries aren’t covered, you still have an opportunity to challenge their decision. Your Los Angeles workers compensation attorney can manage this process for you while you focus on healing and getting back to work when possible.
Who Qualifies for Workers’ Comp in California?
Most employers in California must provide workers’ compensation coverage to their employees. This is also true in many other states. This policy pays out if you suffer injuries at work while performing work-related duties, including:
- Acute injuries, such as from an accident
- Repetitive work injuries caused or worsened by your work
- Some occupational illnesses
All workers classified as employees at a covered workplace should have access to these benefits from the first day they work. This includes full-time, part-time, seasonal, and temporary workers.
What Benefits Are Available Through Workers’ Compensation?
Workers’ comp grants employees injured on the job the time off and medical care necessary to heal and return to work. This process works well for many workers, who receive benefits until they recover and can return to their previous positions, hours, and pay.
According to Workers’ Compensation in California: A Guidebook for Injured Workers, California workers’ compensation includes five primary benefits:
Medical Care Payment
Your employer (and their workers’ comp insurer) will pay for all recommended medical care to help you recover from your workplace illness or injury. Many workers never receive a bill. However, there are often rules about which doctors you can see and where you can go for treatment.
Temporary Disability (Income Loss) Benefits
Income loss benefits are available when you cannot work while undergoing treatment and recovering from your injuries. This benefit pays a portion of your usual pay while you heal and until you can return to your usual hours and position.
Permanent Disability Benefits
There are continuing payments for those who cannot fully recover from their injuries and return to their previous position.
Supplemental Job Displacement Benefits
If you have a lasting injury, you could receive a voucher to pay for retraining, training in a different skill, or other job training courses. This could help you return to a different job with your employer or go to work in a new field.
Death Benefits
When an injured worker dies, workers’ compensation makes a payment to the family (a surviving spouse, children, or parents). This helps cover final expenses, funeral and burial costs, and more.
Which of these you receive will depend significantly on the severity of your injuries and whether you have any long-term disabilities as a result.
What Do I Need to Do When I Suffer a Workplace Injury?
If you are hurt at work, you have rights. Your focus initially should be on getting the medical care you need. Talk to your supervisor or a human resources representative about where you need to go for medical care if possible. If not, your workplace should have information posted about approved doctors. In a life-threatening emergency, call 911 and go to the nearest emergency room.
Next, report your injuries officially. Submit notice in writing of your injuries and where you went for care. There are often forms available for this purpose. You may only have up to 30 days to officially report your injury.
In some cases, a third-party case is also possible. While you cannot sue your employer or a co-worker, other liable parties could be legally responsible for your injuries. The damages available in these claims or lawsuits could overlap with your workers’ comp benefits, but you can seek additional damages through these actions, too.
Discuss Your Workers’ Compensation Injuries and Coverage With Our Team
At KJT Law Group, our team provides free case consultations. A team member can discuss your workers’ comp claim and next steps with you for free. You can learn more about how we help injured workers fight for the benefits they need and deserve. Contact us online or by calling (818) 507-8525 today.
