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What Does Workers’ Compensation Not Cover?

Workers compensation written on blocks holding by a man with blue tie with dollar signs around. What does workers' compensation not cover.

What does workers’ compensation not cover? Workers’ compensation provides coverage for injuries that occur during an employee’s work activities. It does not cover an injury occurring outside the course and scope of employment. If the accident happens outside the employee’s job duties, workers’ compensation does not cover it. Injuries caused during the commute to work and injuries resulting from the employee’s own misconduct or intoxication while on duty are not typically covered by workers’ compensation.

Workers’ Compensation in Kentucky

Workers’ compensation is an insurance program in Kentucky that employers fund. It covers the medical expenses, lost wages, and other related costs of employees injured on the job or due to a workplace accident. If you get injured at work, workers’ compensation will reimburse you for your medical expenses, a portion of your lost income, and future expenses such as long-term medical care, rehabilitation, and future lost income.

The Department of Workers’ Claims (DWC) is the overseeing agency in Kentucky. The DWC’s primary objectives are to promptly evaluate and treat the injured person, investigate the injury, and have physicians determine if there are any permanent impairments and when the injured employee can resume work.

Types of Injuries and Illnesses Covered by Workers’ Compensation

Workers’ compensation is a type of insurance that covers most work-related injuries in Kentucky. If an employee gets injured while working or carrying out duties in the course and scope of their employment, they can receive one of the four types of workers’ compensation benefits. However, injuries that happen before starting work or during breaks are not covered.

Workers’ compensation benefits cover both one-time injuries and occupational diseases. One-time injuries result from a single event, such as falling off company equipment. Occupational diseases are illnesses or injuries that develop over time due to continuous exposure to a toxic substance.

Workers’ compensation provides coverage for a range of injuries, including sprains, fractures, herniated discs, lumbar injuries, joint injuries, injuries resulting from vehicle accidents while on the job, injuries from collapsed scaffolding, heavy equipment failures, exposure to harmful chemicals, burns from hot liquids, repetitive motion injuries, most injuries sustained while working from home, counseling or treatment for a traumatic incident at work or related to work, as well as slipping on icy walkways while on the way to your work assignment.

Exceptions and Limitations to Workers’ Comp Coverage

Workers’ compensation covers medical expenses, rehabilitation expenses, and lost wages resulting from the inability to work. It also pays out death benefits. However, there are limitations and exceptions. There is a limit on lost wages, usually 66 2/3% of your salary. Workers’ compensation does not pay for pain and suffering, and may deny claims due to an employee’s behavior. It also doesn’t cover injuries resulting from:

  • Injuries or illnesses caused by employee misconduct
  • Intoxication
  • Self-harm

A claim may be denied due to pre-existing conditions or previous injuries.

Injuries or Illnesses Caused by Employee Misconduct

In some US states, including Kentucky, employers can defend against workers’ compensation claims if an employee’s willful misconduct caused an on-the-job accident. Willful misconduct occurs when employees deliberately put themselves in danger or purposefully injure themselves. If an employer can prove that the employee was engaging in willful negligence, they may argue against a workers’ compensation claim.

If an employee chooses not to wear the required eye protection while working with hazardous materials and subsequently experiences an eye injury, it could be deemed willful misconduct.

Pre-Existing Conditions or Aggravation of Previous Injuries

Pre-existing medical conditions refer to illnesses or injuries that existed before a workplace accident and were not caused by workplace activity. These conditions include evident injuries like herniated discs, broken bones, torn ligaments, knee, neck, or back injuries. It may also refer to general health conditions such as carpal tunnel, post-traumatic stress disorder, anxiety, depression, arthritis, and age-related spine degeneration. If you have one of these conditions before starting a job, and it is not work-related, you cannot claim workers’ compensation.

However, if your pre-existing condition is aggravated by workplace activity, you may still be eligible to claim workers’ compensation. For instance, if the workplace conduct leads to a new injury that worsens the pre-existing condition, you can file a claim. However, such claims are generally denied, and proving that workplace activities aggravated the pre-existing condition can be challenging. Employers may argue that the symptoms that prevent you from working are caused by your pre-existing condition, not the workplace activities.

How to Determine Aggravation of Previous Injuries

When an employee experiences an injury at work, he or she needs to determine if it’s a new injury, requires new medical attention, or a change in the course of existing treatment caused by workplace activity. If it meets any of these criteria, it’s called an aggravation, and workers’ compensation would cover it.

For example, if a physical therapist has arthritis in his or her lower back and tries to help a patient out of bed, causing a disc in his or her back to bulge, this is a new injury connected to a pre-existing condition and caused by workplace activity. If this injury prevents the person from working, workers’ compensation would cover it.

Workers’ compensation doesn’t cover flare-ups of previous conditions. Exacerbations of pre-existing conditions aren’t considered a new injury and are not covered by workers’ compensation.

It’s important to distinguish between aggravation and exacerbation, and doing so requires the knowledge of a workers’ compensation attorney.

Steps to Report and File a Workers’ Compensation Claim in Kentucky

The following steps can be taken to file a claim:

Report Your Injury to the Manager or Employer

You should report any injuries or acquired illnesses to your employer immediately after you become aware of them. It is recommended that you do this within a week of the incident or discovery, and certainly no later than a month.

Reporting your injury promptly is crucial in filing for workers’ compensation. It starts the process rolling and also provides documentation that you acted promptly after the injury.

You should be as detailed as possible in your report.

Your report should include:

  • The date, time, and location where the accident occurred.
  • Names and contact details of any individuals who witnessed the accident.
  • A description of the accident in detail.
  • Any injuries you sustained as a result of the accident.

Providing any evidence to support your account of events can be beneficial, such as photographs of your injuries, which can be used when filing for benefits with the assistance of your workers’ compensation lawyer.

Get Medical Care

After a workplace injury, your employer should refer you to a doctor for evaluation and care. A doctor is crucial to your health, the workers’ compensation claim process, and your ability to obtain benefits. He or she can prove you have an occupation disease or injury and answer important questions about your prognosis, treatment plan, activity restrictions, and accommodations you require. You can also learn when you can return to work and any necessary accommodations.

File Your Workers’ Comp Claim

To apply for workers’ compensation in Kentucky, you must submit an Application for Resolution of a Claim. The Department of Workers’ Claims will review this form after you submit it, and your employer and his or her insurance company will also be notified. The application will ask you to provide details such as how the accident or injury happened, when you informed your employer about the injury, the type of medical treatment you received, and the name and location of your treating physician.

If you don’t have a lawyer, you must mail the completed application to the Department of Workers’ Claims. However, you can submit the paperwork online if you have an attorney.

Since this application is your official claim for benefits, you must provide accurate, complete, and error-free information. Even a minor mistake can cause delays in the process. After you’ve submitted your application, you’ll receive a letter of acknowledgment. Make sure to keep this document in your records in case any issues arise later on.

Your Claim Is Approved or Denied

If your claim is denied, you have the right to appeal. If your claim is approved, you will be offered compensation, which can be either structured payments over a period or a lump sum.

Negotiate a Settlement

If you receive an offer for compensation that you feel is too low, you have the right to negotiate for a higher amount. A workers’ compensation attorney can help you negotiate a fair settlement. If you fail to agree on a settlement amount, you have the option to take your case to trial.

What Are the Time Limitations and Deadlines to File Your Claim?

In Kentucky, workers’ compensation claims have a statute of limitations of two years. You must file your claim within two years of either suffering a work-related injury in an accident or discovering the injury.

Jay A. Bolotin is a partner at the injury law firm of Young, Reverman & Bolotin. Serving the people of Indiana, Kentucky, and Ohio, Jay dedicates his career to helping clients in the tri-state area obtain financial compensation after suffering serious injuries. He focuses his practice on cases involving car accidents, trucking accidents, dog bites and animal attacks, and other types of personal injury incidents.

Years of Experience: More than 25 years
Registration Status:: Active
Bar Admissions: Illinois, Kentucky, Ohio, Indiana, and Cincinati Bar Association