What Is Not Covered by Workers’ Comp?

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What Is Not Covered by Workers’ Comp?

Workers’ compensation covers most injuries or illnesses that occur as a result of job duties, with few exceptions. In the event of an injury or illness that occurs within the “scope of employment”, a Florida workers’ compensation policy will provide the following benefits:

• Reasonable and necessary medical care for an injury or illness
• Continuing care and follow-up appointments
• 66 ⅔ replacement wages for the difference between current wages and wages prior to the injury
• Limited out-of-pocket expenses, including some prescribed medical devices and transportation to/from appointments

It is important for individuals seeking workers’ compensation in Florida to understand the types of costs that may not be covered by their employer’s policy. Note, too, that every employer in Florida has the freedom to choose its own policy, which will have its own exemptions and coverage limits. We will also provide a brief overview of the types of injury scenarios that are usually not covered under workers’ comp.

If you have questions or feel like you are being unfairly denied benefits after a workplace injury, it is important to contact a Florida workers’ compensation attorney as soon as possible to seek the full amount of benefits you need to recover.

Workers’ Compensation in Florida Provides for All “Reasonable and Necessary” Care up to the Coverage Limit

When you are injured or discover you have an occupational-related illness or condition, workers’ compensation is supposed to pay for the initial treatments you receive and all follow-up care.

In the event of an acute work injury, for example, the costs of emergency transport and emergency medical treatment should be covered. Diagnostic services and testing are, likewise, supposed to be covered. Ambulatory care is also supposed to be covered, in most situations, as is follow-up care that may include long-term rehabilitation.

Similarly, if you discover you have a condition like welder’s lung or a repetitive stress injury, then workers’ compensation is supposed to pay for the appointment required to diagnose your condition and any subsequent care. If the claimant can prove that their condition started earlier, it is possible to get some treatments received prior to the diagnosis covered.

One blanket exception to medical coverage under workers’ comp is that policies are only meant to pay for “reasonable and necessary” treatments. In other words, you can only expect to receive coverage for treatments that are typically used to address your specific illness. Experimental treatments or treatments without proven efficacy are likely not going to be covered, nor are any procedures considered elective.

Many situations lend themselves to “gray areas” where treatment is prescribed but the insurer wants to dispute that the treatment is needed. If a doctor recommends to a person with a back injury to get an adjustable bed frame, for example, the insurer will potentially say the medical device is not covered or request further proof that the device is absolutely necessary.

“Reasonable and necessary” clauses are a common reason for insurance claims denials, and it can take an experienced attorney in order to resolve the dispute in many cases.

Workers’ Compensation Provides Limited Coverage for Out-of-Pocket Expenses

Certain expenses may be covered by workers’ compensation benefits, including prescribed medical devices or over-the-counter medications. The cost of transportation to and from appointments is also typically covered, which can include the costs of parking or public transportation.

However, many out-of-pocket costs are commonly denied by workers’ comp insurers. This can include certain over-the-counter medicines that the insurer considers elective or unnecessary.

Getting a clearly defined prescription for certain items can help, but you ultimately may need to dispute whether or not a cost is covered with the insurer.

Temporary Replacement Wages Are Available for Disability

Workers’ compensation can provide partial replacement wages for individuals who cannot return to work or who must work in a diminished capacity while they recover. The maximum an individual can claim for total disability is 66 ⅔ of the average total wages earned in the months prior. If the claimant has only a partial disability and can return to work in a limited capacity, then workers’ compensation can provide for the difference in earnings made before and after the injury — but only up to a certain extent.

In all situations, workers’ compensation policies in Florida leave out a substantial amount of lost income. This can motivate injured workers to seek out other avenues of compensation, including claims against a non-employer third-party for a personal injury caused by negligence.

Pain and Suffering Are Not Included

Unlike liability policies, workers’ compensation policies do not provide compensation for the injury victim’s own pain and suffering.

Uncovered Injuries

Workers’ compensation insurance in the U.S. is supposed to work under a “no-fault” system, meaning that the cause of the injury and who caused it are not supposed to matter. However, under certain circumstances, a work injury may not be covered.

Outside the scope of employment

If an employee is doing something not technically work-related, like running a personal errand or tinkering with their own machinery while on the clock, it’s possible that their injury could be considered non-work-related. Note, however, that the injury can have occurred outside of the employee’s regular duties. If, for example, they were picking something up from an office supply store on behalf of their boss, then this would likely still be considered within the scope of employment.

Pre-existing conditions

Injuries that existed prior to the employee’s tenure or that occurred outside the scope of employment are not eligible for workers’ compensation benefits. If an injury or condition was made worse in the course of employee duties, then the injury may be eligible for benefits at a reduced rate. 

Unfortunately, insurers may nitpick about what is covered when treatments for a pre-existing condition and a new condition overlap, such as if someone with a fused spine later receives treatment for an acute back injury at work. Hiring an attorney can help you document the medical need for certain treatments and potentially trace them back to a new injury or ailment, increasing the odds the treatment will be covered under workers’ compensation.

Horseplay and fighting

If workers are engaged in non-work-related play, especially of a dangerous nature, then it’s possible that their work injury may not be covered. However, it is important to investigate the circumstances of the accident to determine if the injury would still have been likely even if the employee(s) had not been playing around.

Work injuries involving fights, conflicts, or assaults are also not covered, except potentially in situations where a victim was attacked unprompted and was not directly engaged in a physical conflict prior to the injury.

Gross negligence or recklessness

In rare situations, an employee’s actions can represent a repeated refusal to exercise due caution or obey work instructions. Typically, this will follow after one or more instances of disciplinary action.

What is more likely to happen is that the insurer may slightly reduce the percentage of coverage provided if the employee is found to have intentionally neglected repeated health and safety directives. However, these are extreme scenarios, and workers’ compensation is likely expected to cover injuries in the full amount even if the employee’s own negligence was involved since it is technically a “no-fault” system.

Injuries incurred while under the influence or during the commission of a felony

If the employee was drunk, on drugs, and/or committing a crime at the time the injury occurred, then the employer may be exempted from providing workers’ compensation coverage for the injury.

Speak to a Florida Workers’ Compensation Lawyer Promptly If You Have Been Denied Coverage

Before signing a workers’ compensation settlement or accepting any compensation, be sure to review the total amount of costs that resulted from your work injury. It is possible that the insurer left out benefits for items, wages, or treatments that should have been covered. Once you sign a settlement agreement, it is nearly impossible to reopen the claim. To prevent this situation, have an experienced workers’ compensation attorney in Florida review your case and help you determine what coverage should be available.

You can schedule a free, no-obligation case review with Hoskins, Turco, Lloyd & Lloyd today when you call 866-460-1990 or contact us online.