Exceptions to the No-Fault Rule
In California, workers’ compensation is considered a ‘no-fault’ system. This means that neither the employee or the employer needs to prove that the other was at fault for the workplace injury.
Instead, you generally only have to prove that the illness or injury arose from the ‘course and scope’ of your employment.
However, there are a few exceptions to this rule that you should know.
Intoxication
If your injuries were caused by intoxication or use of drugs or alcohol on the job, you will not be eligible for workers’ comp benefits. However, for you to be denied these benefits, it would have to be proven that the consumption of drugs or alcohol was the primary cause of the injury.
Intentional Infliction
If you purposely inflicted your own injuries, not only will you not receive workers’ comp, but you can also be charged with insurance fraud. Staging accidents or harming yourself in order to receive benefits is illegal.
Horseplay
If your accident was caused by horseplay, your claim can be denied. Horseplay, sometimes called ‘skylarking’, is any situation where an employee is goofing off or messing around at work. In cases involving horseplay, the court determines that when you are engaging in horseplay, your injury does not “arise out of your employment,” which essentially means that you were not doing your job when you were injured.
Fighting
Injuries that occur because you started a fight with another employee or customer are not eligible for workers’ compensation. However, if you are defending yourself because someone else started the fight, you may still be able to get benefits. The critical point is ‘ who threw the first punch’. If that was you, then you will not receive benefits.
These are the major exceptions to the ‘no-fault’ rule to be aware of. In all other cases, you should be eligible for workers’ compensation benefits so long as the cause of injury falls within the scope of your job duties.
It should be noted that the employer or their insurance carrier has the burden of proving that that the exception applies. So, for example, if an employee had a beer at lunch and was later rear-ended in a motor vehicle accident, the employer would have to show that the employee's alcohol consumption caused the injury (not likely in this scenario).
No matter the details of your case, it is always best to enlist the help of a certified workers’ compensation specialist. These experts know the workers’ comp. system inside and out, and can help you file or appeal a case that may involve one of these exceptions.
Cole, Fisher, Cole, O’Keefe + Mahoney is Central California’s leading workers’ compensation and social security disability law firm. With over 30 years of successful experience, we are committed to securing maximum benefits for our clients in the Fresno, California area. Schedule a free consultation today.