As you know, workers’ compensation helps employees in California and elsewhere who were injured on the job. You might wonder if there are some incidents that workers’ compensation won’t cover. At the Law Offices of Hussain & Gutierrez, we are prepared to answer your questions if this is a concern for you.
Understanding When Workers’ Compensation May Not Apply
According to FindLaw, workers’ compensation is not applicable in some cases. The following examples can clarify the situations in which you would not be covered under California’s workers’ compensation laws:
- You were in a motor vehicle accident with the company truck on a business-related errand, and law enforcement detected alcohol in your bloodstream.
- You knowingly bypassed safety procedures with machinery to save time, and you were injured.
- You were in an accident on your way to work, but you were not yet on the clock or on company property.
- You thought you could take time off work and get benefits by deliberately injuring yourself at work.
- You are not an official employee of the company, but an independent contractor.
Legal Definitions That May Affect Your Eligibility
Even though you may have worked with a company for a long time, your employment classification under California Labor Code Section 3351 plays a key role. Individuals who fall outside the “statutory employee” definition may not qualify for benefits.
You may be excluded from coverage if you are:
- An independent contractor or consultant
- A casual or seasonal worker
- A volunteer
- An intern without a formal employment agreement
In California, Assembly Bill 5 (AB5) has further clarified how contractors are classified, using the ABC test to determine worker status.
Common Reasons Why Claims Are Denied
There are specific legal and procedural reasons why a claim might be denied by an insurance carrier or the Workers’ Compensation Appeals Board (WCAB):
- The injury occurred outside the scope of employment
- You were intoxicated or under the influence of drugs
- You engaged in willful misconduct
- The injury was self-inflicted or fraudulent
- You violated safety protocols or ignored company policies
- You failed to notify your employer within the required time
- You refused to be examined by a Medical Provider Network (MPN) doctor
The short answer is: if you were breaking the law or company policy, or not legally classified as an employee, your claim may be denied.
Myths and Misunderstandings About Workers’ Compensation Denials
Myth: If I caused the accident, I can’t get benefits.
Truth: California has a no-fault workers’ comp system, so even if you caused the accident, you’re usually eligible, unless you were engaging in gross misconduct.
Myth: Contractors automatically qualify after working long-term.
Truth: Classification is based on your contract and the ABC test, not tenure.
Myth: Injuries while traveling for work are always covered.
Truth: Only if you’re on a work assignment, not during regular commuting or personal errands.
FAQs
What types of injuries are not covered under California workers’ comp?
Injuries that result from horseplay, fights unrelated to work, intoxication, or intentional self-harm are generally excluded.
What should I do if my workers’ comp claim was denied?
First, request a written explanation from your claims administrator. Then, file an appeal with the Workers’ Compensation Appeals Board (WCAB). Working with an attorney significantly improves your chances of approval.
Can independent contractors receive workers’ compensation in California?
Generally, no. However, if you were misclassified, you may be able to dispute your status under AB5 and seek coverage.
What is a Medical Provider Network (MPN)?
An MPN is a group of healthcare providers selected by your employer or insurer. Disputes involving treatment often relate to whether you were treated inside or outside the MPN.
Can I be fired for filing a claim?
No. Retaliation is illegal under California Labor Code Section 132a. If you’re terminated or demoted after filing a claim, you may have grounds for a lawsuit.
Why You Need Legal Guidance for Denied Workers’ Comp Claims
As you can see, the workers’ compensation process may be more complicated than you might have assumed. You would usually be eligible for compensation even if your injury was your fault, but you could be ineligible if you violated company policies or were breaking the law when the accident occurred.
You might have worked long-term for a company, but you are categorized as a consultant, a casual worker, or a volunteer, which would exclude you from workers’ compensation. Our page on workers’ compensation benefits explains more about your rights after a work-related injury.
Contact a Workers’ Comp Attorney in California Today
If your claim was denied or you’re unsure if you qualify, reach out to the Law Offices of Hussain & Gutierrez. We’re here to fight for your rights and help you navigate the workers’ compensation system in California.
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Offices in Van Nuys, CA
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