Injuries Covered by Workers' Compensation
In general, any injury, illness or disease that arose out of and in
the course of employment is covered for workers’ compensation. The
injury, illness or disease can be one that was caused, contributed to,
or aggravated by a specific incident or by the constant stress or nature
of the job over a period of time. The following represent circumstances
under which injuries are not considered to have arisen out of and in the
course of employment and are, therefore, not covered for workers’
compensation.
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Coming and Going Rule
As a general rule, injuries that occur while coming to work or going
home from work are not within the course of employment and, therefore,
not covered. However, there are exceptions to this rule.
Despite the rule, an injury is covered if it occurred during the period
of employment, at a place where the employee might reasonably have been
expected to be and while the employee was fulfilling the duties of
his/her job conditions under which those duties were to be performed.
For example, if an injured worker parks his/her car in a parking lot
designated for company employees and is injured while walking from the
lot to the employer’s building, then he/she is entitled to workers’
compensation. In such a case, the injury occurred during the period of
employment (the period of employment includes a reasonable time before
and after actual workday hours), at a place where he/she is expected to
be and while doing something under conditions created by the employer
(walking in the company parking lot). There are many factual situations
that will allow an injured worker to collect workers’ compensation under
an exception to the Coming and Going Rule.
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Deviation from Employment
As a general rule, if an employee deviates from performing his/her
job duties, i.e., does something for a personal benefit, then any injury
that occurs during the period of deviation is not within the course of
employment and, therefore, not covered. Once the employee returns to the
workplace or returns from the deviation to the course of employment,
then any injury that occurs after that point is covered. If the
deviation is solely for the employee’s benefit, then any injury that
occurs during the period of deviation is not covered; if the employer
derives some benefit from the deviation, then the injury would be
covered.
Horseplay
Injuries that occur during horseplay among employees are not within the
course of employment and, therefore, not covered. However, if the
employer was aware of such activity and acquiesced to it, then an injury
that occurs during horseplay would be covered as being within the course
of employment.
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Fighting
An injury that occurs during a fight is only covered if the fight was
about some matter related to employment.
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Intoxication/Intentional Act
An injury that is intentionally caused by the injured worker or by
his/her intoxication is not covered.
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Aggravation of Pre-Existing Condition
An employer takes its employees as it finds them. Therefore, an
employee’s pre-existing condition that is worsened by a work related
injury is covered for workers’ compensation, regardless of whether or
not the pre-existing condition itself was work related. This is commonly
referred to as an aggravation of a pre-existing condition. The
determining factor is whether the work injury or activity contributed to
the injury by accelerating or aggravating the pre-existing condition.
The work injury or activity can be a specific incident or the constant
stress or nature of the job that worsens the pre-existing condition over
a period of time.
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Recurrence of Injury
A recurrence is a prior work related injury which has resulted in a
return of disability without being aggravated by a new injury. There is
often a dispute between insurance companies as to whether a disability
is the result of an aggravation or a recurrence. The dispute arises
because the determination of whether a disability is the result of a
recurrence or aggravation determines which insurance company is
responsible to pay workers’ compensation. If the prior injury becomes
disabling without being aggravated by a new injury or work activity,
then the insurance company for the employer where the original injury
occurred pays workers’ compensation for disability as a recurrence. On
the other hand, if there is a subsequent work related injury or activity
that worsens the prior injury, then the insurance company for the
employer where the subsequent injury occurred pays workers’ compensation
as an aggravation.
If an injured worker returns to work for at least 26 weeks, after
having collected compensation for an injury, and then suffers a
recurrence of disability from the previous injury, the weekly
compensation rate for the recurrence is recalculated based on the
average weekly wage for the period of time prior to the date of the
recurrence. Read full text of statute –
28-33-20.1.
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Flow-From Conditions
A “flow-from” is a term used to define an injury or medical condition
that
results from a work related injury. For example, if an injured worker
suffers an injury to his right hand and, as a result, begins to overuse
the left hand to compensate for the useless right hand, then any injury
to the left hand that results from overuse is considered an injury that
“flowed from” the original work related injury. Other examples would be
a knee injury caused by a person who fell when their leg gave out
because of a work related back injury and depression which resulted from
the psychological effect of a work injury.
A “flow-from” injury is covered just like any other work related injury.
In fact, if an injured worker recovers from the original work related
injury but continues to be disabled as a result of the “flow-from”, then
weekly benefits will continue.
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