Workers’ compensation claims can arise one of two ways: 1) an accident or 2) by occupational disease. This post looks at the three elements a claimant must prove in injury by accident cases.

One note: Before going into the elements of the claim, it is important to consider whether there was, in fact, an employee/employer relationship. All employers regularly employing 3 or more employees in the same business (though not necessarily at the time of injury) are required to carry workers’ compensation insurance. We most often see this issue arise in the case of independent contractors.

1. Accident

The accident requirement means something unusual or unlooked for must occur – a departure from the employee’s normal work routine. It is not an accident if the employee is performing his normal job duties and nothing out of the ordinary or unusual occurs.

Exception – Back Claims

Back claims are the one major exception to the accident requirement. Although an accident may occur, an accident is not necessary. All that is required is that the employee be able to point to a specific time during the course of his normal work duties that his back suddenly began to hurt. The back pain cannot develop gradually over a long period of time.

Special Injury – Hernia

Under NCGS 97-2(18), for a hernia to be a compensable injury, the injury must result in the sudden appearance of a hernia (or rupture) that develops immediately following an accident. The hernia must not have been there prior to the accident.

2. Arising out of and in the course of employment

For an accident to arise out of and in the course of employment, the accident must have a causal connection to the employment and must have occurred at a place and during a time when the employee was working.

Coming and Going Rule

Injuries suffered coming to or going home from work are generally not compensable. This is known as the “Coming and Going rule.” There are four exceptions to the coming and going rule including: 1) premises exception; 2) traveling salesman exception; 3) special errands exception; and 4) contractual exception.

3. Leads to injury

The third prong of a workers’ compensation claim requires that the employee show, often through expert testimony, that the injury was more likely than not, or more probable than not, work related. A mere possibility is not enough. However, the injury does not have to be the sole cause of the injury, only a significant factor.

Issues that often arise in this part of the analysis include: 1) aggravation of a pre-existing condition; and 2) last injurious exposure (more often in occupational disease claims.)