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What Does Workers Comp Cover & Not Cover?

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After a workplace accident that leaves you injured, workers’ compensation can be a pillar of hope in the coming days, weeks, months, or longer. Workers’ compensation benefits are meant to keep you financially afloat while you attempt to recuperate from your debilitating or disabling injuries. But workers’ comp isn’t a cure-all. It only covers so much, and there are expenses not covered by the average workers’ compensation policy.

What is Covered by Workers’ Compensation?

Every workers’ compensation policy is unique due to factors established by the insurance company selling the plan and state-level laws that regulate it. However, there are some basic coverage allowances that you can find in most workers’ comp plans, no matter where you call home.

Workers’ compensation policies generally provide:

  • Medical expenses: Full coverage for all necessary medical expenses related to the claimant’s workplace injuries should be provided through workers’ comp. However, insurance companies can complicate the matter by trying to argue that certain treatments are elective, not necessary, and, therefore, not covered.
  • Ongoing care: When a claimant’s injuries are serious enough to cause prolonged complications, some workers’ compensation policies can entirely cover rehabilitative therapy costs. With some injuries warranting years of physical or occupational therapy, this provided benefit can save the claimant tens of thousands of dollars if not more.
  • Vocational retraining: If a claimant is permanently disabled in a way that prevents them from returning to their previous line of work, then workers’ compensation can provide vocational retraining courses at no cost. The objective is to allow the claimant to return to work in a capacity that pays the same or more than their previous job position.
  • Lost wages: Workers’ compensation coverage can also open the doors for an injured worker to access disability benefits that replace missing wages. Disability pay typically provides two-thirds of the claimant’s average weekly wages until they recover or can return to work to some capacity.
  • Funeral expenses: When a claimant passes away from a work injury or occupational illness, financial benefits through their workers’ comp policy can be given to their surviving family members and named beneficiaries instead. Funeral and burial expenses are often covered in this way, up to a cap.

What is Not Covered in Workers’ Compensation?

As mentioned, workers’ compensation cannot do everything. Even the best policies on the insurance market will have coverage gaps that could surprise you.

No matter your workers’ comp plan, you will probably not receive coverage if you are injured due to:

  • Roughhousing: No workplace permits its employees to roughhouse or start fights. If you are hurt because you were “goofing around” or because you assaulted someone, then you will likely receive no coverage at all. However, you can get workers’ comp coverage if someone else assaults you while on-the-job or their roughhousing hurts you collaterally.
  • Intoxication: Being intoxicated by alcohol or impaired by a narcotic at the time of your workplace injury can also make you lose workers’ compensation coverage. There is a gray area, though, in cases involving a workplace accident caused by someone who was on an approved medication that their employer knew was being taken while working.
  • Deliberate negligence: Workers’ compensation policies will not cover any injury that you intentionally caused. It only covers true accidents, regardless of who caused them.
  • Isolated emotional harm: Many workers’ comp policies can provide benefits to people suffering from mental health difficulties, like depression or anxiety. Although, the benefits might not be provided if the source of a claimant’s mental health difficulties or emotional trauma is entirely unrelated to their line of work. For example, first responders can suffer PTSD related to what they see and do on-the-job, so they can usually get workers’ comp for their emotional trauma. But someone who is experiencing PTSD from a car crash that happened on their day off would be ineligible.

If you need help figuring out what is and is not covered by your workers’ compensation policy, then you can come to Alvandi Law Group, P.C. in Orange County for experienced legal guidance. Our workers’ comp attorneys can assist with every step of your workers’ compensation case, from initial filings to challenging wrongful denials. Dial (800) 980-6905 now to learn more.


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