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When might an employee not be covered?

The general assumption regarding workers’ compensation benefits is that all eligible employees have access to them, regardless of fault. This offers you (as an employer in Troy) an added sense of security in knowing that not only is your workforce protected, but so are you. Yet could there be situations where an employee is excluded them receiving workers’ compensation coverage?

The New York State Workers’ Compensation Board identifies those types of employees not eligible for coverage. Some of the more common groups include: 

  • Volunteers for non-profit organizations 
  • Clergy members
  • Real estate and insurance agents operating as independent contractors
  • Participants (including coaches and players) in amateur athletic events 

For the most part, all other employees (whether they be employed by a government agency or in the private sector) are eligible for benefits through either state-sponsored programs or commercial benefit providers. 

Are there scenarios where an eligible employee might be denied coverage? While workers’ compensation benefits are typically available regardless of who is at fault for the injury, there may indeed be rare scenarios where a provider may withhold benefits. Remember that your workers’ compensation provider operates like an insurance company; it investigates claims to decide if there is merit behind them. If, say, your employee was under the influence of drugs or alcohol when they were injured, or they were injured while violating a company policy, they could potentially be denied coverage. The same may be true if they were not on the clock at the time of the injury, or the injury was self-inflicted. 

You might think that an employee being denied workers’ compensation benefits leaves you a target for civil action. Yet again, because your workers’ compensation providers functions as a form of insurance, you cannot be sued for coverage determinations.