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Some Injuries Fall Short of Qualifying for Workers’ Compensation


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10/6/2016
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No matter how careful you may be, workplace accidents have the potential to happen anytime and anyplace. Even a person with a mundane desk job can injure himself at work when he least expects it. Fortunately, workers’ compensation laws are in effect to help cover employee expenses when they get hurt on the job—at least to a point.

Although many employees are comforted by the belief that their employer must provide workers’ compensation coverage for any and all work-related injuries, this isn’t necessarily true. In fact, workers’ comp laws have several restrictions and requirements for what is—as well as for what isn’t—covered.

Workplace Injuries: Ineligible Claims and Restrictions

It can be incredibly frustrating and frightening to be denied compensation for an injury that you received at work. Workers’ compensation benefits exist for the very purpose of protecting workers from financial hardships after being hurt while doing their job. Facing medical bills, household bills, and other costs—all while trying to recover from an injury—will feel nearly impossible when a regular paycheck is not coming in.

When it comes to deciding to pursue a workers’ compensation claim, you’ll need to throw out assumptions and employ a little practicality. Under Texas Labor Code Section 406.032, a workers’ compensation insurance carrier is not liable for compensation if an employee…

  • Was injured while intoxicated. If your injury is the result of intoxication at work or other intentional negligence, your claim will likely strike out.
  • Was purposely trying to hurt himself or another person, was injured by another person because of personal reasons, or was engaging in horseplay when he was injured. If the sustained injury was caused as a result of the employee’s blatant negligence, the employer is not responsible.
  • Was voluntarily participating in a work-related social gathering outside of work. Off-duty recreational, social, or athletic activities that do not constitute part of the employee’s work-related duties are not covered by worker’s comp. However, if the activity was reasonably expected or required because of the employment, a claim can be filed.
  • Was injured by an “act of God.” When injuries result from a natural disaster or other unavoidable accident, the employer is not required to cover injury expenses. However, if the employee’s job or duties inherently put him at a greater risk than the general public to sustain such injuries, his employer may be responsible for treatment.
  • Was only mildly injured. Minor “booboo” type injuries need not apply; if you did not need to seek professional medical help in order to treat it, it would not be covered.

It should go without saying that your injury must occur while performing your duties of employment in order to collect benefits. If you are injured when you pop over to a coffee shop in between meetings or on your commute home from the office, it will not be covered. That is not to say that you physically need to be in the office, however, to be covered. If your job involves making sales calls or deliveries and you are injured while completing those duties, your injury would be covered.

A Denied Claim

It’s a shame when employees make bad decisions at work and then end up injured and unable to collect workers’ compensation benefits. However, there are situations when someone who should be entitled to workers’ comp ends up with a denial from the insurance company.

When your claim is denied, if it wasn’t for ineligibility reasons, it may be because:

  • Your employer or your employer’s insurance company is questioning the nature of your injury. You may be accused of having a preexisting condition, or that you injured yourself in a location other than your workplace. The insurance company may even claim that your own carelessness or negligence caused the injury.
  • You filled out the claim forms incorrectly. Workers’ compensation forms are extremely confusing and require a certain amount of legal know-how to understand.
  • You filed the claim past its eligibility deadline. Texas laws place time limits on workers’ compensation claims. When this point has been passed, you’ll be unable to file.

Most denials are accompanied with an option to appeal the decision. Simple matters, like missing information on your paperwork, can often be resolved very quickly. A denial based on a dispute regarding your injury, however, can be more difficult to fight.

These are the times when a workers’ compensation attorney should be consulted; your lawyer know what needs to be done and how you should proceed to obtain the benefits you need to get back on your feet. Contact attorney Steve Lee today to see how we can help you stand tall after a workplace accident.



Category: Construction, Refinery, Industrial, On the Job Injuries and Workers' Comp

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