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Which Injuries Are Compensable?
Every seven seconds, someone in America is injured at a workplace. In 2017, there were 5,147 workers killed on the job. That’s nearly 100 per week or more than 14 deaths every day.
Those statistics are from the National Safety Council and Occupational Safety and Health Administration (OSHA), which is hard-pressed to oversee the totality of workplace hazards. OSHA has one compliance officer per 59,000 workers.
But everyone knows that accidents can happen. Everyone knows that accidents do happen. It’s helpful to know what illnesses and injuries are the most common to trigger claims for workers compensation injuries, along with the maladies considered a bit more unusual or rare.
For an acceptable workers compensation claim, the injury must be work-related and that requires setting some defining parameters for workplace injuries.
How to Determine an Injury Is Work Related
Basically, a work-related injury must happen while doing something on behalf of your employer, or in the course of employment. Many of those injuries are easily defined and recognized at the workplace itself, but they could occur in company-owned trucks or other locations, as long as the employee was doing something connected to the job.
Some work-related illnesses or injuries might be surprising. It could include lung cancer that was caused by second-hand smoke at a restaurant that permits smoking. It could include a sprained ankle after falling off a ladder. It could include carpal tunnel syndrome caused by too much time at a computer keyboard with no breaks.
Of course, there are some gray-area incidents and some potential surprises there, too.
A company-sponsored holiday party — even at a bar — is considered a work-related activity. If you took a fall there, the injury would be covered by workers comp. Now if you and your manager went to that same bar for after-work drinks and you fell, it wouldn’t be considered “work-related’’ because that’s not an official company event.
If an injury happens during a lunch break, it might be considered “work-related’’ if it occurs at the company cafeteria, on other employer-owned grounds or if it has a legitimate connection to the workday (such as taking a client to lunch at a restaurant).
If there’s a car accident or an injury during a car ride, it could be covered by workers comp if the employee is performing a job-related task, such as making a delivery, driving another employee for business purposes, running a work-related errand or driving from one worksite to another. Taxi drivers or truck drivers can file workers comp claims if they are injured during regular work hours.
There have even been occasions when “horseplay’’ — or other instances where employees were disregarding workplace safety rules — constitutes a workers comp claim. But state laws and courts are divided on the issue.
The legal definition of horseplay is an act of having rough fun that is dangerous and can result in injuries. Horseplay is not generally accepted in the workplace because it doesn’t contribute to productive work being accomplished. So how can someone be involved in horseplay, yet still be compensated for injuries sustained?
Here are three examples from the same state (Missouri) that show how the same laws can be affected by court interpretation.
What happened: A man injured his knee and arrived at work using crutches. A co-worker, seeking fun, tipped him over and the man fell down and severely injured his already hurt knee.
The ruling: The man was the victim of horseplay, not the instigator. He was entitled to workers compensation.
What happened: A restaurant worker, having fun with his co-worker, kicked his leg several feet into the air from under the co-worker. The floor was wet. The worker, who kicked his leg, fell down and injured his leg and groin.
The ruling: The worker was entitled to workers compensation. The court ruled the act wasn’t horseplay because it was normal behavior for the restaurant wait staff and not considered unacceptable behavior.
What happened: At a construction site, a worker tries to playfully bump his co-worker with the rear-view mirror of his truck. The co-worker had shaken his backside at the man. The man in the truck tried to play along. While reversing the truck, instead of the rear-view mirror, the man bumped his co-worker with the bed of his vehicle and injured the co-worker.
The ruling: Workers compensation was denied. It was an act of horseplay beyond the regular scope of work. The injured man also was engaged in the event.
Other examples for what could happen under the broad definition if you are injured at work:
- Even if alcohol is involved, an injury could be considered work-related if it was provided at a work-sponsored event.
- Anxiety or depression could be covered if they were sustained on the job (or caused by the job).
- Pre-existing conditions (if worsened during the course of employment) might be covered in some instances.
- The definition of “employee’’ often swings a claim’s success. Certain workers — such as domestic workers, agricultural workers, seasonal workers or undocumented workers — are exempt from workers comp in many states.
You will hear this term a lot in workers compensation claims, but what does it mean?
A compensable injury is caused by an accident that occurs in the course of an employee’s work. From that, the employee injured at work is entitled to receive compensation.
Common Work-Related Injuries
According to a five-year study (2010-14) of workers comp claims by the Travelers Indemnity Company, the most common work-related injuries are:
- Strains or sprains (30% of total claims)
- Cuts or punctures (19%)
- Contusions (12%)
- Inflammation (5%)
- Fractures (5%)
These five areas account for 71% of the total workers comp claims.
According to the Travelers’ data, inflammation injuries accounted for the most average days off for the worker (91), followed by fractures (78), strains/sprains (57), contusions (27) and cuts/punctures (24).
The average cost of those claims was$42,400 for fractures, followed inflammation ($24,500), strains/sprains ($17,000), cuts/punctures ($8,200) and contusions ($8,000).
But overall, the costliest claims were none of the five most common injuries. The costliest claims were amputation ($102,500), dislocation ($97,100), electric shock ($55,200), crushing ($54,600) and multiple trauma ($50,000).
According to OSHA, out of 4,674 private-industry worker fatalities in 2017, there were 971 (or 20.7%) that occurred in construction. Put another way, one in five worker deaths were in construction.
So obviously, when it comes to workers comp claims, the construction industry gets plenty of attention. The leading causes of construction worker deaths have been called the “Fatal Four.’’ They were responsible for 59.9% of construction worker deaths in 2017. Elimination of the Fatal Four would save the lives of 582 workers annually.
Here is the Fatal Four:
- Falls (accounting for 39.2% of total construction deaths)
- Struck by object (8.2%)
- Electrocutions (7.3%)
- Caught-in/between (5.1%)
The “caught in between” category refers to when workers are caught-in or compressed by equipment or objects. That includes being stuck, caught or crushed in collapsing structures, equipment or materials.
Occupational Disease or Illness
An occupational disease or illness is caused as a result of the work or occupational activity. Sometimes, an occupational disease is identified by being shown as more prevalent among the workers than the general population.
Some common occupational diseases or illnesses include lung diseases, skin diseases, overuse syndrome, carpal tunnel syndrome, computer vision syndrome and lead poisoning.
It’s different than injuries caused by accidents, which sometimes mean carelessness or not following a proper procedure. Occupational diseases or illnesses can invade a worker’s life through no fault of their own — or simply by being present in the workplace. With a workers comp claim involving an occupational disease or illness, there is generally the burden on the employer or insurer to show that the disease came from another source (other than the workplace).
Musculoskeletal Disorders and Repetitive Strain Injury
Work-related musculoskeletal disorders (WMSD) or repetitive strain injuries (RSI) are a group of painful disorders of muscles, tendons and nerves. They are caused by overuse of the musculoskeletal system,
They are different than traumatic injuries of the muscles, tendons and nerves due to accidents such as lacerations or fractures.
WMSDs are caused by arm and hand movements, such as bending, straightening, gripping, holding, twisting, clenching and reaching. They are part of daily life, but become hazardous in the workplace due to the continual repetition, speed of the movements and lack of recovery time between them.
Workers can notice the onset of WMSDs through joint stiffness, muscle tightness, redness and swelling of the affected area. They might experience sensations of “pins and needles,’’ numbness, skin color changes and decreased sweating of the hands.
Some of the common WMSDs include:
- Tendonitis — repetitive motions of the wrist, shoulders and arms
- Epicondylitis — repeated or forceful rotation of the forearm and bending of the wrist at the same time
- Carpal Tunnel Syndrome — repetitive wrist motions
- DeQuervain’s Disease — repetitive hand twisting and forceful gripping
- Thoracic Outlet Syndrome — prolonged shoulder flexion while extending arms above shoulder height
- Tension Neck Syndrome — prolonged restricted posture
This is a real thing. According to OSHA, an estimated $242-million is spent annually on workers comp for hearing loss disabilities. In 2018, U.S. businesses paid more than $1.5-million in penalties for not protecting workers from noise. OSHA estimates that 22-million people are exposed to damaging work noise each year.
The National Institute of Occupational Safety (NIOSH) and OSHA have set loud-noise standards for the workplace. NIOSH noise standards are set at 85 decibels for an eight-hour period, while OSHA’s permissible noise limit is 90 decibels for an eight-hour period. Employers are required to protect employees with the proper equipment when workplace noises exceed these levels.
If an employee feels their hearing loss was caused by workplace noise, they can undergo an audiogram (a test in a soundproof room conducted by an audiologist or otolaryngologist).
There are a couple of tricky parts here. The audiogram results should be compared to the audiogram conducted upon hiring or from previous employers (sometimes, these don’t exist because there are no mandatory standards). Without that proof, it can result in a battle of wills between the workers comp adjuster and the employee/attorney.
It must also be determined whether the hearing loss is conductive (caused by an ear defect due to disease or injury) or perceptive (caused by workplace noise, aging or infectious disease). If the otolaryngologist determines it’s a conductive hearing loss, the claim can be denied.
Workers comp standards can vary by state, but coverage generally kicks in if there is a permanent hearing loss or a loss to 10% or more in both ears.
Mesothelioma is a workplace exposure to asbestos, which is the leading cause of occupational cancer in the United States. Asbestos remains in old buildings and schools, so people will continue to be exposed and face mesothelioma or asbestos-related diseases.
Getting a successful Mesothelioma claim for workers comp can be difficult. Most claims must be filed within an established time frame — usually well after there has been occupational exposure to asbestos. Because of that time lag in the diagnosis, there’s usually a much greater success rate in pursuing a personal-injury or wrongful-death lawsuit.
Workers Comp for Stress and Anxiety
According to the American Institute for Preventative Medicine, stress is the chief cause for about two-thirds of all doctor’s office visits. Sure enough, courts recognize emotional or mental stress-related injuries and it’s covered by workers comp insurance.
But only about half of all states support emotional or stress-related workers comp laws.
The burden of proof lies with the employee, who must prove that the stress has reached a level of disability in order for workers comp to be awarded. The stress-related mental injuries can result from one-time events, such as a firefighter experiencing a particularly traumatic fire.
Unlike a broken arm or the loss of a limb, stress-related claims are psychological in nature, not orthopedic or neurological. There is a higher standard of proof due to the nature of the claim.
There are varying levels of stress in all jobs and it is handled differently by each individual. Sometimes, there are heightened levels of anxiety (causing an inability to reason). Sometimes, stress can cause physical manifestations or permanent impairment.
The upshot on stress and workers comp claims: It’s complicated.
Post-Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder (PTSD) is usually associated with military personnel, but it can be experienced by anyone exposed to a traumatic experience.
Even in the workplace.
There are many cases of work-related stress in high-risk occupations, such as police officers, firefighters and emergency medical crews. But other occupations could cause PTSD, depending on whether they cause psychological trauma, hallucinations, flashbacks or nightmares.
Not all cases of PTSD are compensable under workers comp laws, which vary by state.
Some states have coverage if the PTSD was caused by an extraordinary event and others allow claims for psychological conditions caused by stress at work, even if it’s gradual and not unusual for the job. In the cases where PTSD has mental stress that produces mental injury, some states won’t accept any claims, while others have compensable claims only if the mental stimulus is sudden.
In all states where PTSD is a compensable workers comp injury, the PTSD must be diagnosed at least 30 days after the traumatic event occurred by a licensed psychiatrist or psychologist.
Not every injury is covered by workers comp. Some are too minor and incidental. Think of it this way: If the accident can be fixed with a first-aid kit, then it probably won’t qualify.
But there are other reasons why an injury won’t qualify for workers comp:
Commuting to and from Work — There’s a “coming and going’’ rule that applies to injuries for commuters. Travel to and from your fixed work site is not considered within the scope of employment. So, if you’re hit by a car on your way to work, it’s not covered by workers comp. But if you drive a company car, if you don’t have a fixed work site or you were running a work errand, your injuries probably will be covered.
Recreational Activities — Social events such as a company picnic, holiday party or happy hour — might not be covered by workers comp. But some conditions — if the employee was required to attend or if the employer benefitted from the worker’s attendance — could change the dynamics.
Intoxication or Substance Abuse — Most states have workers comp laws that exclude injuries caused by a worker’s intoxication or substance abuse.
Workplace Horseplay and Fighting — Horseplay and practical jokes are considered outside of the scope of employment, so injuries are generally not covered. There are exceptions. If your employer tolerated ongoing horseplay, it will be viewed differently. If you were an innocent bystander, you probably will be eligible for benefits.
Having a pre-existing illness or condition can complicate a workers comp claim. But in most cases, it won’t completely disqualify you from benefits.
Pre-Existing Condition Related to Prior Workers Comp Claim — If you previously injured the same body part in another workplace accident, the benefits will be slightly reduced to account for the previous claim. But your employer will be required to pay for medical bills and treatment related to the new work-related injury. It’s important to note the distinction between the aggravation of a previous work-related injury and a new work-related injury involving the same body parts.
Pre-Existing Condition Not Related to Prior Workers Comp Claim — Sometimes, workers can have pre-existing conditions stemming from aging or a prior injury, which is worsened by a work-related injury. You should receive benefits to account for the worsening of the injury based on a doctor’s diagnosis.
Pre-Existing Unrelated Condition — You should receive benefits. Your regular health insurance could cover the pre-existing condition if treatment is needed.
- Middlesworth, M., (2018, May 15), The Definition And Causes Of Musculoskeletal Disorders (MSDs). Retrieved from https://ergo-plus.com/musculoskeletal-disorders-msd/
- N.A. (2018) Occupational Health And Safety Administration. Retrieved from https://www.osha.gov/oshstats/commonstats.html
- N.A. (2018) Work-Related Musculoskeletal Disorders. Retrieved from https://www.ccohs.ca/oshanswers/diseases/rmirsi.html
- N.A. (2018) Occupational Noise Exposure. Retrieved from https://www.osha.gov/SLTC/noisehearingconservation/
- Simpson, K., (2018) Types Of Injuries And Workplace Illnesses That Qualify For Workers Comp. Retrieved from https://blog.safetyculture.com/industry-trends/types-of-injuries-and-workplace-illnesses-that-qualify-for-workers-comp