§ 12-110 Compensable injury – Exclusions.
A. In order for a claimant to receive any benefits under this chapter, the claimant must demonstrate by a preponderance of evidence that he or she sustained a compensable injury.
B. A claim for a compensable injury must be initiated by reporting the injury and filing a claim pursuant to Sections 12-107 and 12-108.
C. A compensable injury must both arise out of employment and occur within the course of employment. An injury that does not meet both these requirements and any other applicable requirements is not a compensable injury.
D. A claim will be rejected, payment of any benefits will be discontinued, and/or any reported injury, illness, or condition will not qualify as a compensable injury, as appropriate, in the event of any of the following:
1. The claimant fails to adhere to the reporting requirements, filing requirements or statute of limitations established under Section 12-107 or 12-108;
2. The injury is caused by intoxication, alcohol, illegal drugs, or the unlawful use of any other controlled substance;
3. The injury is either intentionally or recklessly self-inflicted, or an employee unreasonably refused to obey written or verbal instructions which, if obeyed, would have reasonably prevented or significantly reduced the likelihood of injury or death;
4. Suicide by the employee;
5. The injury results from an altercation in which the injured employee was the initial aggressor, whether or not those injuries are caused by a third person or fellow employee;
6. The injury results from or occurs during the commission, by the injured employee, of any crime, including any misdemeanor or felony;
7. The injury results from voluntary participation in any off-duty recreational, social, athletic, or other activity that is not part of the employee’s usual and customary employment-related duties;
8. The claim is filed after a notice of suspension, termination or layoff, and it is determined by the Administrator that the filing of the claim was retaliatory in nature;
9. The injury is deemed by the Administrator to have been an idiopathic injury;
10. The injury results from participation in an activity deemed to have been horseplay;
11. At the time of injury, the employee refuses or fails to utilize or wear personal protective equipment or other safety apparatus that is considered a prerequisite of the job, where such refusal or failure would be admonished or not permitted by the casino if it were discovered, and the injury is caused by such a refusal or failure to wear or use that personal protective equipment or other safety apparatus;
12. The injury qualifies as a psychiatric injury as defined in this chapter, or any other purely emotional or mental injuries, except:
a. Where such injury is the direct result of a sudden and extraordinary employment event; or
b. Where such injury is the direct result of a severe, extreme, or abnormal compensable injury;
13. The injury results from or is attributable to secondhand smoke, which is considered an inherent risk of employment that an employee assumes by accepting a position with the casino;
14. The claimant refuses to cooperate or fails to use his or her good-faith best efforts in cooperating in the investigation of the claim, thus impeding the Administrator’s right to discovery;
15. The employee, without good cause shown, fails to present or appear for a scheduled independent medical examination, and the employee received sufficient prior notice of the appointment;
16. The Administrator’s acceptance of a claim or decision regarding benefits is based on a misrepresentation or willful omission of a material fact which, if known to the Administrator or casino, would have resulted in denial of the claim or provision of benefits at lesser levels than what was actually paid in reliance upon the misrepresentation or willful omission;
17. The injury is determined to have been a flare-up or exacerbation of a preexisting injury, illness, or condition where no aggravation or worsening of symptoms are attributable to employment or where the employment merely served as the stage for the incident to occur without specific industrial causation;
18. Cumulative injuries where the employee has been employed for less than six (6) consecutive months; or
19. The injury occurs while the employee travels to or from work, unless such travel is in connection with the performance of employment duties. (Res. 2022-44 (Exh. A))