Time, Space and Cause: A Case Study on Course and Scope

In the complex world of work-injury claims, the most important question in the life of a work-injury claim may be this one:  Did the injury arise from and occur during the course and scope of employment? 

A recent case brings into clear focus the subtle differences in time, space and cause – and the importance of their combination in the three-boundary issue facing those making coverage decisions.

Spinning His Wheels

An employee’s assigned and documented job duties are to protect store assets, primarily to protect merchandise from shoplifters. He performs a very valuable service for his employer and also may have time to assist customers and other co-workers in between his required walks and perimeter inspections. Let’s call him Mr. Asset Protection.

One fateful day, Mr. Asset Protection deviated from his normal route, stopped into the fitness and exercise department, and became Mr. Exercise Bike Rider. While “testing” the exercise bike, his feet unfortunately became inexplicably tangled during his dismount, causing him to fall and sustain a very serious injury.

First responders indicate Mr. Exercise Bike Rider immediately reported that he was “trying out the bike for himself” and was considering buying one for personal use. Mr. First Responder’s statement and observations were preserved in writing as part of the claim investigation. Mr. First Responder and Mr. Exercise Bike Rider both confirm there were no customers, no co-workers and certainly no shoplifters involved in this event. 

Pre-planning with PartnerSource

This case is a great example of partners working together (PartnerSource clients, consultants, claim service professionals and medical partners) to arrive at the correct coverage decision on a difficult claim.

This coordination began well before this fateful exercise bike ride: It started with a customized plan that defines course and scope to fit the business of the employer. Every business is different; therefore, it makes sense that a written definition of that employer’s course and scope of employment should be unique to that business. It’s one of the many aspects of plan creation that PartnerSource advises on.

Years before this event, during this client’s plan design process, the PartnerSource attorney team leader and risk manager customized this plan to specifically exclude “personal exercise” activities.  The reason for this was based on a known pattern that employees often used personal time and lunch breaks to walk or use available exercise equipment onsite to meet personal activity needs and personal goals. The risk manager felt strongly that these specific personal exercise activities should not be included in the course and scope definition of their plan.  Because the Texas Option plan document can address unique exposures and experiences of the employer, this was considered and accounted for in the plan design. This tailored plan provision applied very directly to this case and provided a precise definition that confirms Mr. Exercise Bike Rider’s activity was expressly personal -- and not covered by an occupational injury plan. 

Coverage Analysis

Every course and scope decision is a three-boundary calculation: In order to be covered by this employer’s Texas Injury Plan, any accident or event must include all three elements connected to the business of the employer – time, space and cause:

1. Time: Did an accident or injury occur during the course and scope of employment? In this case, YES, Mr. Exercise Bike Rider was “on the clock,” so he meets the timing requirement.

2. Space: Did it occur within the course and scope of employment or on the employer’s premises, within the physical work area? NO. Based on Mr. Exercise Bike Rider’s job description, manager statements, and witness statements, he had exited his work route for an excluded and expressly personal purpose.

3. Cause & Control: Did the injury arise solely and directly from work tasks? (Or is personal time, personal property, or personal effect a proximate cause?) NO. Details of the claim investigation confirm Mr. Exercise Bike Rider was on a personal shopping deviation and the employer’s plan specifically excluded the activity from the course and scope of employment. When the employee exited his work route, and began to engage in a task for personal gain or purpose, his actions were specifically excluded from the plan’s course and scope of employment definition. Therefore, any resulting injuries are not covered by the plan. 

Ride to the Finish Line

The client’s plan covered initial emergency care and transport to protect the employee. Then, a clear and thoughtful adverse benefit determination was sent to the employee communicating the plan’s benefit denial. This plan’s coverage denial was later upheld on appeal, confirming a prudent application of properly interpreting course and scope of employment by time, space and cause.  This employee’s event failed to meet course and scope by space (outside of his work area) and cause (personal exercise).

At PartnerSource, our consultants have the privilege of working with risk and claim professionals on legal concepts that define work-related injuries. These plans are NOT a one-size-fits-all solution. One of the many advantages of designing a customized Texas injury plan is having the freedom to customize a very specific and accurate course and scope of employment definition tailored to the business of the employer.

Please contact your PartnerSource team leader with any questions.