Eligibility for Workers' Compensation Benefits
The workers’ compensation system is essentially a compromise. In exchange for being shielded from liability in a personal injury lawsuit, employers accept responsibility for paying these benefits even if they were not at fault. The system is meant to be simpler and more efficient than pursuing a case in civil court. However, eligibility for workers’ compensation benefits still involves meeting certain requirements. Benefits are generally available only to employees of employers that have workers’ compensation insurance, and the employee must comply with deadlines and other procedural rules imposed by state law. Also, the accident or illness must have arisen out of the employee’s job duties. This is often the most contested element of eligibility.
Status as an Employee
This requirement can lead to a dispute over whether the claimant is an independent contractor rather than an employee. Independent contractors are not entitled to workers’ compensation benefits. (Nor are volunteers, with some exceptions.) In an effort to reduce their costs, some employers may misclassify certain employees as independent contractors. Other employers may misclassify employees because they are ignorant of the law in this area, which can be complex in some states.
The definitions of employee and independent contractor vary across the states. Being labeled as one status or the other on certain documents does not necessarily mean that the label applies. Filling out tax paperwork for independent contractors, for example, does not alone make you an independent contractor. Instead, the decision of whether you are an employee will depend on factors related to how much you control your work and how the business interacts with you.
Employer Coverage
This requirement is usually straightforward, since most employers must have workers’ compensation coverage under state law. Texas is the only state in which employers are not required to purchase this coverage. Other states may carve out exceptions for businesses with only one employee, agricultural operations, charities, and other unusual types of organizations.
Even if state law does not require them to get workers’ compensation coverage, most employers find it prudent to purchase it anyway. This option exposes them to less risk and cost than potentially being sued in a personal injury lawsuit based on a workplace accident, which is the alternative. Some employers are self-insured, but the majority of employers get coverage through an insurer or the state.
Exempt Workers
People who work in certain professions or industries are usually exempt from workers’ compensation under state law. These often include agricultural workers, especially people who work at small farms, as well as seasonal workers. People who provide care for elderly people or children in private homes may be exempt, although some states apply an exemption only to part-time domestic workers. Foreign nationals who do not have legal status in the U.S. are usually covered, but the laws of some states are changing in this area.
More complex issues can arise when employees of staffing agencies are injured on the job while working for their temporary employer. Workers’ compensation coverage should apply to them if they meet the requirements above. The question becomes whether the insurance of the staffing agency or the insurance of the temporary employer applies. The two insurers may need to litigate the issue, which can delay benefits but does not affect the worker’s entitlement to them.
The Work-Related Requirement
Sometimes it is obvious that an accident arises out of the job, such as when a worker falls off a scaffold at a construction site or slips and falls on a warehouse floor. However, there are other situations in which causation is less obvious. Injuries may occur in work-related activities outside working hours and outside the main physical location of the company. A worker usually will meet this requirement as long as they were performing a task for the benefit of their employer, but special rules apply to time off the clock, employee misconduct, and other circumstances.
