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:

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.

Why A is correct

A standard exclusion in medical expense policies is treatment for injuries that are covered by workers' compensation, because the employer's comp policy is the primary payer for occupational injuries and the health plan should not duplicate that benefit. Emergency ambulance transport, office visits for acute illness, and prescription drugs are ordinary covered services under most medical expense contracts. This exclusion is one of the common exclusions and limitations tested under individual medical expense insurance, alongside experimental treatment and cosmetic surgery, which appear in the already-validated question bank.

Why the other options are wrong

• B) Emergency ambulance services are typically covered medical expenses, not excluded.
• C) Physician office visits for acute illness are routine covered benefits.
• D) Prescription drugs are a standard covered service, not a common exclusion.

Memory hook

Workers' comp pays for the job injury, so the health plan stays home.