What Injuries or Illnesses Are Not Covered By Workers' Comp?

While most work injuries are covered by workers' comp, there are a handful of exceptions.

Importantly, workers’ compensation is a no-fault system. It doesn’t matter if you or your employer’s carelessness caused the injury. In general, all that matters is that your injury arose out of your employment. However, there are a few specific situations where an injury is not covered by workers’ compensation.

How Workers’ Comp Defines a Covered Injury

Workers’ compensation covers injuries and illnesses that are within the “course and scope of your employment.” Most courts have interpreted this phrase broadly and erred on the side of covering injuries, to the benefit of employees making claims for benefits. In general, if you were engaged in an activity that benefits your employer, your injury will be covered.

If you are injured at your workplace while performing work duties, you will receive workers’ comp. For example, a dishwasher who slips and falls while working in a restaurant kitchen would be covered. .Injuries caused by repetitive work activities are also within the course and scope of employment. For example, if constant gripping and grasping at work causes carpal tunnel syndrome, you are eligible for workers’ comp. (To learn more, see our article on repetitive stress injuries in workers’ comp.)

What If I’m Injured at Work During a Break?

If you are taking a break in your company’s break room or cafeteria, your injuries might still be covered by workers’ comp. In many states, it is considered a benefit to the employer when workers stay onsite for meal or rest breaks—because it saves time and because the employee remains accessible to the employer.

If you leave your workplace, you typically will not be eligible for benefits if you are hurt during your break, unless you are furthering your employer’s interests. For example, your injury will likely be covered if you were picking up boxed lunches for a meeting or you were having an off-site business meeting during lunch.

What If I’m Injured at Work After I Clock Out?

Most states cover injuries that occur at the workplace, even if you have clocked out for the day. This generally includes injuries that happen in a parking lot that is owned or controlled by your employer on your way to and from the building for work. However, once you’re done with work and leave the company’s premises, any injuries that happen are not covered.

What If I’m Injured Off-Site?

If you are injured while you’re away from the workplace, your injury will be covered only if you were performing activities that benefited your employer. For example, courts have found injuries to fall within the course and scope of employment when they happen:

  • while working from home or taking a work call in the car
  • during professional education or job-related training
  • while traveling between two work sites, and
  • while off-duty during business travel.

Every state has different rules for what qualifies as within the course and scope of employment. If you need help determining your eligibility for workers’ comp benefits, contact an experienced workers’ comp lawyer.

Common Exclusions From Workers’ Compensation

While every state has different workers’ compensation laws, there are some common situations where injuries are considered to fall outside the course and scope of employment. If any of these scenarios applies to you, contact a workers’ comp lawyer to find out more about your state’s workers’ comp laws and your eligibility for benefits.

Commuting to and From Work

If you are injured while commuting to and from work, the “coming and going rule” typically applies. Under this rule, travel to and from your fixed work site is not considered within the scope of your employment. For example, if you are hit by a car during your regular morning commute to the office, your injury will not be covered by workers’ comp.

On the other hand, your injuries will probably be covered by workers’ comp if you drive a company car, if you don’t have a fixed work site, or if you were running a work errand. For example, a traveling salesperson may receive workers’ compensation benefits if the salesperson was injured while driving from home to the first client meeting of the day. Likewise, an executive assistant who is injured while picking up the company president’s dry cleaning on the way into work would likely be covered.

Recreational Activities

Most workplaces offer team building and recreational opportunities for their workers. Depending on the circumstances, injuries at a social event—such as a company picnic, holiday party, or happy hour—might not be covered by workers’ comp. Certain factors make it more likely that the injury will be covered, including the following:

  • the employee was required to attend the event, or reasonably believed that attendance was required
  • the employer benefited from the worker’s attendance (for example, because the event included a work-related presentation or brainstorming session), or
  • the activity occurred on the employer’s premises during business hours.

However, if an event is clearly voluntary and for the employee’s benefit only, the injury will usually not be covered by workers’ comp. Whether or not a claim is covered by workers’ comp is a very fact-specific inquiry. Do not assume that your injury isn’t covered by workers’ comp just because it happened at a company social event. (To learn more, see our article on company-sponsored events and workers’ comp.)

Intoxication or Substance Abuse

Most, if not all, state workers’ comp laws specifically exclude injuries caused by the worker’s own intoxication. For example, if you fall from a ladder because you’ve been drinking, your claim will probably be denied. If you have evidence that the accident was unavoidable or not your fault, you may still be eligible for benefits. For example, if you were working on a factory line, and another worker strikes you from behind with a lift truck, you may be eligible for benefits even if you were under the influence.

Some states—including Florida, North Carolina, Ohio, and Texas—assume that an injury is non-occupational if drug testing shows high levels of alcohol or drugs. However, intoxication defenses can still be difficult for employers to prove. If your drug and alcohol test was significantly delayed, it may not prove you were intoxicated at the time of the accident. (For example, a mildly positive marijuana test taken two days after an accident may be insufficient evidence.)

Intoxication-related injuries involve a detailed factual and legal analysis. Do not assume that you are ineligible for workers’ comp simply because you failed a drug test. An experienced workers’ comp lawyer may be able to prove that your injuries were within the course and scope of your employment.

Workplace Horseplay and Fighting

Because horseplay and practical jokes are considered to fall outside of the scope of employment, related injuries are typically not covered by workers’ compensation. However, there are exceptions to this rule. For example, if your employer tolerated ongoing horseplay, your injuries may be covered. Likewise, if you were an innocent bystander, you will probably also still be eligible for benefits.

Similarly, most injuries caused by workplace fights or altercations are not covered by workers’ compensation. However, if the fight is over a work-related issue, you might still be eligible for benefits. For example, if you get into a fight with a coworker about your favorite sports team, it’s probably not a covered injury. But, if your coworker hits you after you complain about his or her poor job performance, you may be eligible for benefits.

Every state has different workers’ comp rules and exceptions (and exceptions to the exceptions). If your employer or its insurance company argues that your injury is not covered, you should contact an experienced workers’ compensation lawyer. A lawyer can evaluate your claim and tell you how likely you are to succeed on an appeal.

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