Some employees may assume that Workers’ Compensation will cover any injury they experience while on the job. While a majority of injuries are indeed covered, there are some circumstances where injuries are excluded from Workers’ Compensation eligibility. If your Workers’ Compensation claim has been denied based on an ineligible injury, it is important to know whether such a denial is legal.
Work-related injuries that occurred while you were on the job that was not intentional or caused by your illegal actions are covered by Workers’ Compensation. The injury must be reported to your employer within the required timeframe, and you must receive treatment from approved medical providers for the injury to be covered.
When you are unsure whether your workplace injury is eligible for Workers’ Compensation, schedule a free case review with the Philadelphia Workers’ Compensation attorneys at Lerner, Steinberg & Associates. Call (215) 355-6400 to speak to someone today.
What Injuries Are Covered Under Pennsylvania’s Workers’ Compensation Law?
77 Pa.C.S § 411(1) defines injury as used in Workers’ Compensation law as arising during the course of employment. § 411(2) of the same law includes an occupational disease or illness caused by hazardous workplace conditions in the definition of an injury covered by Workers’ Compensation.
There is a myriad of injuries that can be experienced while working. Some injuries are caused by pure accidents, like tripping and falling. Jobs involving more physical activities, like lifting heavy objects, can also produce injuries covered by Workers’ Compensation. The fact that a job normally involves duties likely to cause injury does not exempt the employee from claiming compensation. Workers’ Compensation could cover even minor repetition injuries like arthritis if you can establish causation between the work duties and the injury. If you are unsure whether your injury is covered, reach out to our Pennsylvania Workers’ Compensation lawyers for some guidance.
The word accident infers a lack of fault, but Workers’ Compensation can also be sought for injuries that are caused by the negligence of others. Whether someone was at fault or not is immaterial to the claim. Third-party negligence is a common cause of a covered injury. For example, if a safety mechanism fails on an employee’s equipment, the resulting injury would be covered by Workers’ Compensation, even if the safety mechanism is defective. Here, the third-party manufacturer of the safety equipment may be liable for the injury, but that does not prevent the injury from being covered by Workers’ Compensation.
What Injuries Do Not Qualify for Workers’ Compensation?
Workers’ Compensation casts a wide net over injuries covered by insurance. However, there are some exceptions. An injury that you purposefully cause is probably not going to be covered. Additionally, covered injuries must occur while performing your job duties, so some employers may argue that your injury was caused when you were not doing your specific job responsibilities. If your claim has been denied because the injury is not covered, call our Pennsylvania Workers’ Compensation attorneys for assistance.
Intentional Injuries
Intentional injuries are specifically excluded by law. Purposefully causing your own injury in the hopes that you will receive a Workers’ Compensation payoff is insurance fraud and strictly illegal. In the same vein, injuries caused by intentional illegal behavior are not covered. This is frequently seen when an employee’s alcohol intoxication or drug-influenced behavior causes an accident. Injuries caused by deliberate misconduct that is not part of your job, like roughhousing or fighting, are likely not eligible for compensation.
However, if someone intentionally harms you while you are doing your job, that injury would likely be covered. As an example, a nurse who is assaulted and injured while caring for a patient can filed a Workers’ Compensation claim. Call our Bucks County Workers’ Compensation lawyers if you are worried your injury may be excluded.
Commuting
Injuries that result from commuting to or from work are also excluded. Workers’ Compensation is specifically for injuries suffered while performing a job, and commuting is an activity that is not considered part of the job. However, an injury suffered while in transit may be covered if you must drive or travel somewhere as part of your job. For example, an employee who is in a car accident while bringing a business deposit to a bank may be able to recover Workers’ Compensation. Injuries do not need to be experienced at a workplace but must be experienced while performing your job responsibilities.
Procedural Issues
Finally, some procedural requirements must be followed to ensure Workers’ Compensation insurance covers your injury. All reporting deadlines must be followed. The best approach is to inform your employer about your injury as soon as feasible after it has occurred. Injuries reported more than 120 days after they happen are not eligible for Workers’ Compensation. Additionally, many companies have a list of approved medical providers for diagnosis and treatment. If you do not see an approved medical provider, see your own doctor, or fail to follow physician instructions, your claim may be denied for not following medical provider requirements.
What Can I Do If My Employers Says My Workplace Injury is Not Covered?
If your Workers’ Compensation claim has been denied and the reasoning is that your injury is not covered, you are not out of luck. A claim denial can be appealed to the Office of Adjudication. When your claim petition is filed, your case will be assigned to a Workers’ Compensation judge. The judge will schedule a hearing for your claim, where both you and your employer will present your position and relevant evidence.
To prepare for this hearing, you will need to establish the facts of your case and collect any evidence available to support your position. This can include your own testimony, coworker testimony, medical test results, physician testimony, or evidence that you were performing your job duties at the time of the injury. For example, records of your supervisor’s instructions or a list of your job duties could be helpful to establish that you were acting in the course of your employment. After the hearing, the judge will examine all the testimony and evidence and issue a written opinion. The employee or the employer can further appeal this decision to the Workers’ Compensation Appeal Board if they disagree with the outcome.
While you are not required to hire an attorney for a Workers’ Compensation hearing or appeal, these hearings are complex legal proceedings that may be difficult to navigate without legal training. Your employer and their insurance company will be represented by counsel, which could put you at a disadvantage if you do not have your own lawyer. Our Berks County Workers’ Compensation attorneys have experience with these proceedings and offer knowledge and aggressive advocacy.
Do Not Wait to Seek Legal Advice for Your Pennsylvania Workers’ Compensation Claim
Lerner, Steinberg & Associates has a team of Delaware County Workers’ Compensation attorneys who can help evaluate your injury’s eligibility for compensation and fight against any claim denials. Call us today at (215) 355-6400 for a free review of your case.