A worker is injured on the job and receives treatment under the state workers' compensation system. Under a typical major medical policy, the injury is most likely:
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Major medical policies commonly exclude injuries or illnesses that are covered by workers' compensation or another government disability program. The rationale is simple: the medical expense has a designated payer, and insurance is designed to restore a loss rather than create a windfall by duplicating benefits. The exclusion applies to on-the-job injuries, so the hospital and physician bills fall on the employer's workers' compensation coverage rather than on the injured worker's own major medical policy. Agents should be able to identify this exclusion as one of the standard limitations carved out of comprehensive medical coverage.
Why the other options are wrong
- B) Major medical policies do not cover everything; occupational injuries payable under workers' compensation are a standard exclusion, so the blanket 'every injury' claim is factually wrong.
- C) The exclusion generally applies regardless of whether the workers' compensation carrier has denied the claim; job injuries belong to the workers' comp system, not to a contingent coverage switch.
- D) No reduced-coinsurance carve-out exists for work-related care; the coverage is excluded rather than discounted, so the work-related status changes nothing about payment.
Memory hook
On-the-job injuries belong to workers' comp, not to your major medical policy — one loss, one payer.