Accidents the Fund does not cover

It is Article 4 of Act 45-1935, the article listing the excepted accidents: those occurring under the three circumstances the Act describes are not compensable work accidents and give no right to compensation to the worker or their beneficiaries.

This guide serves any worker whose case the Fund has denied or is questioning by invoking their conduct, and their beneficiaries when a death is in dispute. It also serves the employer who wants to know what the Act excludes, because Article 4 gives the employer no power to decide: the Administrator is who determines it.

• That the accident be work-related: Article 4 only excludes cases that would otherwise be compensable.Verified against the official source
• For the drunkenness exception, that the drunkenness was the cause of the accident: the Act conditions it with the words "provided the drunkenness was the cause of the accident".Verified against the official source
• For the reckless-imprudence exception, that the imprudence was the only cause of the injury, in the article’s own words.Verified against the official source

• The Administrator’s written decision, if the case has already been denied: it is what gets appealed to the Industrial Commission.
• Evidence of the circumstances of the accident — witnesses, conditions of the place, instructions received — because the two conditioned exceptions are won or lost there.

1. 1

   Step 1: Read the whole article: there are three cases

   Article 4 says that the following are not compensable work accidents and therefore give no right to compensation to the worker or their beneficiaries: "(1) When the worker tries to commit a crime or to injure their employer or any other person, or when they voluntarily cause the injury. (2) When the worker is drunk, provided the drunkenness was the cause of the accident. (3) When the worker’s reckless imprudence was the only cause of the injury." That is the entire article. There is no hidden fourth exception.

2. 2

   Step 2: Drunkenness alone excludes nothing

   The second exception does not say "while drunk". It says "when the worker is drunk, provided the drunkenness was the cause of the accident". That clause is part of the Act’s text, not an interpretation. A worker who had been drinking but whose accident was caused by something else — a scaffold that gave way, a vehicle that hit them, a machine that failed — does not fall into the exception merely for having drunk. The question that decides is one of cause, and it must be answered with evidence of the accident.

3. 3

   Step 3: "Only cause": if anything else contributed, the exception does not apply

   The third exception is the narrowest of the three, because the Act demands exclusivity: the reckless imprudence must have been "the only cause of the injury". It is enough for another cause to have concurred for the exception, by its own words, to fall. That is why the details of the place and the moment matter: what protective equipment there was, what instructions had been given, what state the equipment was in, whether anyone else was involved. The Act does not define "reckless imprudence", and this guide does not give it a definition the Act did not give it.

4. 4

   Step 4: The first exception: crime, assault or self-inflicted injury

   The first exception covers three behaviours and none carries a condition: trying to commit a crime, trying to injure the employer or any other person, or voluntarily causing the injury. Here the Act does not require the conduct to have been "the only cause" or "the cause" of anything: it describes the circumstance and excludes it. It is the most direct of the three exceptions.

5. 5

   Step 5: If you are denied, the decision is appealed

   A denial under Article 4 is made by the Fund’s Administrator, and like any other decision of theirs it can be taken to the Industrial Commission under Article 9. That appeal has its own term and its own procedure, which the guide on appeals to the Industrial Commission explains. What this guide makes clear is what has to be proven for the exception to apply, which is not the same as what often gets said on the shop floor.

There is nowhere to apply: Article 4 is not a procedure, it is the list of exclusions the State Insurance Fund’s Administrator applies within the case you already have open. If the decision excludes you, the forum to review it is the Industrial Commission.

• Believing that having drunk, by itself, closes the case: the Act conditions that exception on the drunkenness having caused the accident.
• Reading the third exception as "if you were reckless, there is no case", when the text requires the recklessness to have been the only cause.
• Accepting a verbal denial: what is appealed to the Industrial Commission is the Administrator’s decision.
• Failing to gather evidence of the conditions of the place, which is exactly what decides whether another cause concurred.
• Confusing Article 4 with Article 14: 4 excludes accidents; 14 deals with workers the Act does not cover.

These are the government pages this guide is based on.

• Corporación del Fondo del Seguro del Estado (CFSE)

  Fondo del Seguro del Estado

  bvirtualogp.pr.gov