1 WORKERS COMPENSATION OVERVIEW I. Philosophy of the Virginia Workers Compensation Act The Virginia Workers Compensation Act is a compromise between employers and employees which addresses the interests of both parties. In a typical personal injury case, the injured party (plaintiff must prove that the wrongdoer (defendant was negligent. Then, the injured party must establish the extent of their damages (personal injury, property damage, economic injury, etc. The injured party is also capable of recovering punitive damages (punishment against the wrongdoer and money for pain / suffering. The wrongdoer (defendant can raise certain defenses to fight the claim such as assumption of risk, fellow servant, and contributory negligence. This can be a fairly complex, time consuming, and an expensive endeavor for both sides. Although not exactly accurate, the framework of the workers compensations system is premised upon the injured worker assuming the role of the plaintiff and the employer assuming the role of the defendant. The Virginia Workers Compensation Act eliminates some burden of proof elements for the plaintiff (referred to as claimants and eliminates standard defenses for the defendant (referred to the employer/insurer The ultimate goal of the system is to provide speedy, wage and medical benefits to the injured worker, while the employer avoids the additional liabilities of a negligence suit. Humphrees v. Boxley Bros. Co., 146 Va. 91, 135 S.E. 890 (1926. In other words, an injured worker need not prove that the employer was negligent in causing his accident/injuries and the employer cannot be sued for negligence
2 (including expensive punitive damages or pain and suffering. II. Virginia Workers Compensation Law 101 Not every accident which occurs on the job or during work hours constitutes a covered workers compensation claim under the laws of Virginia. There are two primary elements which must exist for an accident (or disease to be covered under the Virginia Workers Compensation Act. First, the accident must arise out of the employment and, second, the accident must occur in the course of the employment. If either of these elements is missing, the accident is not a Virginia Workers Compensation Claim. A. Arising out of Virginia Code defines Injury as,...only injury by accident arising out of and in the course of the employment... In order to establish an injury by accident, a claimant must prove (1 an identifiable accident; (2 that occurs at some reasonably definite time; (3 an obvious sudden mechanical or structural change in the body; and (4 a causal connection between the incident and the bodily change. Chesterfield County Fire Department v. Dunn 9 Va. App. 475, 476, 389 S.E.2d 180, 181 (1990. It is important to understand that an injury does not arise out of employment simply because an employee suffers an accident or injury while at work. There are two primary principles utilized by different jurisdictions when analyzing whether an accident arises out of employment. One principle is the positional risk doctrine. The positional risk doctrine generally requires that the injured employee prove merely that his or her accident occurred
3 during the time and place of employment. Royster Clark v. Bays, 1999 WL Virginia rejected that doctrine and accepted the actual risk doctrine. For an accident to arise out of employment in Virginia, the origin or cause of the injury must be a risk connected with the employment. That risk must be an actual risk of employment, not merely the risk of being injured while at work. Taylor v. Mobil Corp., 248 Va. 101, 107, 444 S.E.2d 705, 708 (1994. The actual risk doctrine,...requires only that the employment expose the workman to a particular danger from which he was injured, notwithstanding the exposure of the public generally to like risks. Olsten v. Leftwich, 230 Va. 317, 319, 336 S.E.2d 893, 894 (1985. [A]n injury arises out of the employment, when there is apparent to the rational mind upon consideration of all the circumstances, a causal connection between the conditions under which the work is required to be performed and the resulting injury. Bradshaw v. Aronovitch, 170 Va. 329, 335, 196 S.E. 684, 686 ( Stairs A fall from stairs is only compensable if either a defect exists in the stairs or the employee falls as a result of a condition of the employment. County of Buchanan Sch. Bd. V. Horton, 35 Va. App. 26, 29, 542 S.E.2d 783, ( Slip and Fall In slip and fall cases, The Commission has long held that it is unnecessary for the claimant to positively identify the substance or condition of the workplace that caused her slip and fall where reasonable inferences can be made from the record as to the cause of such incident. Claughton v. County of Halifax School Board, VWC File No
4 (4/14/99. As a practical matter, however, a claimant who can positively identify a substance or liquid causing his slip and fall will have an easier time obtaining benefits. 3. Idiopathic Injury An idiopathic injury is,...caused by a preexisting personal disease of the employee. PYA/Monarch v. Harris, 22 Va. App. 215, 468 S.E.2d 688, (1996citing Southland Corp. v. Parson, 1 Va. App. 281, 283, 338 S.E.2d 162, 163 (1985. When an employee s injuries result from an idiopathic condition and no other factors intervene or operate to cause or contribute to the injuries sustained as a result of the idiopathic condition, no award shall be made. PYA/Monarch v. Harris, 22 Va. App. 215, 468 S.E.2d 688 (1996. The effects of an idiopathic injury are compensable if the employment places the employee in a position increasing the risks of a fall from heights or near machinery. This is also true in a situation where the idiopathic condition triggers while the claimant is in a moving vehicle such as a diabetic seizure while driving. Southland Corp. v. Parson, 1 Va. App. 281, , 338 S.E.2d at 164 (1985. For example, if a claimant suffers a brain seizure and falls from a roof while working the injury would be compensable. If the same claimant s brain seizure occurred while he was sitting at his desk the day before, no benefits for injuries sustained would be paid. 4. Awkward Position Generally, acts such as walking, bending, or turning, without other contributing factors are not risks of employment. Southside Virginia Training Center v. Ellis, 33 Va. App. 824, 829, 527 S.E.2d 35, 37 (2000. An otherwise non-compensable claim could be deemed compensable if the evidence reflected a claimant suffering an accident while
5 working in an awkward position. 5. Sexual Assault Injuries which are the result of a sexual assault are controlled by Virginia Code which states, in part,: A. Any employee who, in the course of employment, is sexually assaulted, as defined in , , , or , and promptly reports the assault to the appropriate law-enforcement authority, where the nature of such employment substantially increases the risk of such assault, upon a proper showing of damages compensable under this title, shall be deemed to have suffered an injury arising out of the employment and shall have a valid claim for workers compensation benefits... Virginia Code For a sexual assault to arise out of the employment, the evidence must establish that,...the attack was directed against the claimant as an employee or because of the employment. Carr v. City of Norfolk, 15 Va. App. 266, 269, 422 S.E.2d 417, 418 (1992. The nature of the employment must substantially increase the risk of the assault. Id. at 269, 422 S.E.2d at Death In 1938 the Supreme Court of Virginia established a presumption regarding accidents which cause death: Where an employee is found dead as a result of an accident at his place of work or nearby, where his duties may have called him during the hours of his work, and there is no evidence offered to show what caused the death or to show that he was engaged in his master s business at the time, the court will indulge the presumption that the relation of master and servant existed at the time of the accident, and that it arose out of and in the course of his employment. Sullivan v. Suffolk Peanut Co., 171 Va. 439, 444, 199 S.E. 504, 506 (1938. Merely finding a corpse at the place of employment without evidence of an accident is not enough to warrant
6 the presumption. Fennell v. Tarmac, Court of Appeals of Virginia, Record No (February 12, 2002 B. In the Course of For an injury to be deemed compensable, a claimant must prove that his injury arose out of and in the course of his employment. County of Chesterfield v. Johnson, 237 Va. 180, 376 S.E.2d 73 (1989. These are separate and distinct elements. The arising out of component was discussed previously. Generally, a claimant satisfies the in the course of element by proving that the accident occurred,...within the period of employment, at a place where the employee was reasonably expected to be, and while doing something which was reasonably incident to his employment. Hercules, Inc. v. Stump, 2 Va. App. 77, 79, 341 S.E.2d 394, 395 (1986. The in the course of element refers to time, place, and circumstance under which the accident occurred. Sentara Leigh Hospital v. Nichols, 13 Va. App. 630, 414 S.E.2d 426 (1992. Accidents which occur on the employer s premises during work hours clearly occur in the course of employment. Other situations are not so clear and will be discussed below. 1. Coming and Going Rule As a general rule,...an employee going to or from the place where her work is to be performed is not engaged in performing any service growing out of and incidental to her employment. Kendrick v. Nationwide Homes, Inc., 4 Va. App. 189, 190, 355 S.E.2d 347, 347 (1987. There are three exceptions, however, to this rule which are (1 where the means of transportation used to go to and from work is provided by the employer or the employee s travel time is paid for or included in wages; (2 where the way used is the sole means of
7 ingress and egress or is constructed by the employer; and (3 where the employee is charged with some duty or task connected to his employment while on his way to or from work. Id. at 191, 355 S.E.2d at Parking Lots If an employee is injured in a parking lot owned by the employer, the accident may be deemed to have occurred in the course of employment if the circumstances indicate that the reason the claimant was in the parking lot was not personal in nature. 3. Personal Comfort Doctrine Virginia recognizes that certain acts which are clearly personal in nature will be deemed to have occurred in the course of employment in certain situation. In Bradshaw v. Aronovitch, the Supreme Court held: Such [personal] acts as are necessary to the life, comfort, and convenience of the servant while at work, though strictly personal to himself, and not acts of service, are incidental to the service, and injury sustained in the performance thereof is deemed to have arisen out of the employment. A man must breathe and occasionally drink water while at work. In these and other conceivable instances he ministers unto himself, but in a remote sense these acts contribute to the furtherance of the work. 170 Va. 329, 337, 196 S.E. 684, 687 (1938. This principle is commonly called, the personal comfort doctrine. Accordingly,...occasional breaks and excursions for food, drink, rest and restroom visitation are deemed to be in the course of employment. Ablola v. Holland Road Auto Center, Ltd., 11 Va. App. 181, 183, 397 S.E.2d 541, 541 (1990. There are some requirements for a claimant to utilize this doctrine, however. The injured worker must use,...the facilities furnished to him by the employer or...not depart from the employer s
8 premises or go to some place thereon where he has no right to be. Kraf Constr. Servs., Inc. v. Ingram, 17 Va. App. 295, 299, 437 S.E.2d 424, 427 (1993. III. Benefits Available to Injured Workers A. Medical and Vocational Benefits Virginia Code sets forth the scope of medical and vocational benefits available to injured workers which are the responsibility of the employer. Arguably, it is the most important benefit because it places the cost of medical care on the employer and serves the goal of getting the injured worker healed as soon as possible so he can return to work. Richmond Memorial Hospital v. Allen, 3 Va. App. 314, 349 S.E.2d 419 (1986. The employer is liable for all reasonable, necessary, causally related, and authorized medical expenses incurred by the injured worker. Press v. Ale, 1 Va. App. 153, 336 S.E.2d 522 (1985. The employer is typically inclined and motivated to bring the injured worker back to work as soon as possible. When this is not the case, or the injured worker is too disabled to return to work, but capable of performing light or sedentary work, the employer or claimant may request vocational rehabilitation to assist the injured worker to find suitable, light duty employment. Virginia Code B. Wage Loss Benefits Virginia Code and provide the authority for temporary total disability and temporary partial disability. In Virginia, two kinds of wage loss benefit are available. Temporary total disability is paid when an injured worker is not working at all. Temporary partial disability is paid when an injured worker has returned to some light duty
9 employment earning less than his pre-injury average weekly wage. Both kinds of wage loss benefits are calculated upon the injured workers pre-injury average weekly wage. Normally, the average weekly wage is determined by calculating the average, pre-deduction pay of the injured worker in the 52 weeks prior to the accident. That figure, then serves as the basis for determining the proper temporary total and/or temporary partial benefits. The injured worker is paid 2/3 of his average weekly wage for his temporary total benefits. For temporary partial disability, he is paid 2/3 the difference of his average weekly and his new light duty wage. C. Permanent Loss. Virginia Code provides injured workers with benefits for permanent loss of use to certain body parts and permanent wage loss benefits for their entire life in some circumstances. 1. Permanent Partial Loss. The Virginia Code provides for payment to injured workers who suffer permanent ratable loss to most of the body (arms, fingers, legs, vision, hearing, etc. except for the spine/back. Typically, the treating physician will assign a rating to the injured body part and payment is made pursuant to the schedule set forth in Virginia Code Permanent Total Loss. Most injured workers are limited to 500 weeks of financial compensation. The medical coverage has no time limit. In cases of extreme injury such as paralysis, brain injury, and amputations, the Code provides for lifetime financial compensation.
10 SETTLEMENTS RELATIONSHIP BETWEEN WORKERS COMPENSATION LAW AND SOCIAL SECURITY DISABILITY LAW I. Social Security Offset Practitioners who represent clients who are receiving both workers compensation benefits AND social security disability benefits require a basic understanding of the manner in which workers compensation payments affect social security disability payments. 1 The United States Code 42 U.S.C. 424a states, in part,: 424a. Reduction of disability benefits (a Conditions for reduction; computation If for any month prior to the month in which an individual attains the age of 65 - (1 such individual is entitled to benefits under section of this title, and (2 such individual is entitled for such month to -- (A periodic benefits on account of his or her total or partial disability (whether or not permanent under a workmen s compensation law or plan of the United States or a State, or (B...the total of his benefits under section 423 of this title for such month and of any benefits under section of this title for such month based on his wages and self-employment income shall be reduced (but not below zero by the amount by which the sum of - (3 such total of benefits under sections 423 and 402 of this title for such month, and (4 such periodic benefits payable (and actually paid for such month to such individual under such laws or plans, exceeds the higher of - (5 80 per centum of his average current earnings U.S.C. 424a. 1 This section will deal primarily with the manner in which the Social Security Administration deals with monthly workers compensation payments before settlement. The Social Security Administration addresses workers compensation settlements in a different manner which will be discussed below. 2 Section 423 refers to disability insurance benefits. 3 Section 402 refers to Old-age and survivors insurance benefits.
11 This provision is best explained by an example. Let s assume we have an injured worker whose average current earning is $30,000 per year or $2,500 per month. 80% of this monthly figure is $2000. That number establishes the ceiling for the total amount our worker can receive in combined monthly workers compensation benefits and social security benefits. Now, let s assume that the injured worker receives workers compensation benefits of $1670 per month and would normally receive $1000 per month in social security disability benefits. In that case, the injured worker would be $670 over his limit and social security would reduce his monthly benefits by $670 for a total monthly payment of $330. When a claimant settles his workers compensation claim, it is important to account for the interplay between workers compensation and social security benefits in the workers compensation settlement documents. Because the injured worker will receive a lump sum payment and/or annuity, the settlement documents must amortize the proceeds over the expected life of the claimant. (See Exhibit B. Medicare s Interest 4 The Federal Government enacted two programs to provide health benefits for disabled individuals; Medicaid and Medicare. If a person is unable to work and meets certain financial criteria establishing poverty, Medicaid is available through Title XVI (SSI. If a disabled citizen is insured and meets certain work and earning requirements, then Title 4 This section will address Medicare s interest in payments for medical expenses before a workers compensation settlement. Issues to consider in the context of a workers compensation settlement will be discussed below.
12 II, Social Security Disability Insurance (DIB is available. DIB provides a disabled worker with health benefits through Medicare. Claimants, attorneys, insurers, and employers have encountered increased enforcement of Federal laws relating to individuals who suffer a workplace injury and have a social security claim. Specifically, the departments of the Federal Government charged with administration of the Medicare program are enforcing federal laws designed to avoid Medicare paying for medical expenses relating to a work injury which should be paid by the workers compensation carrier. Medicare has been a Secondary Payer for medical bills arising from workers compensation claims since the inception of the Medicare program. The laws which establish this are commonly known as the Medicare Secondary Payer Laws per 42 U.S.C. 1395y (b(2 and 1862 (b(2(a(ii of the Act. The relevant portions of the Act state as follows: (A Payment under this sub-chapter may not be made, except as provided in subparagraph (B, with respect to any item or service to the extent that... (ii Payment has been made, or can be reasonably expected to be made promptly (as determined in accordance with regulations under a workmen s compensation law or plan of the United States or a State or under an automobile or liability insurance policy or plan (including a self-insured plan or under no fault insurance... (B Conditional payment... (ii...in order to recover payments under this sub-chapter for such an item or service, the United States may bring an action against any entity which is required or responsible (directly, as a third-party administrator, or otherwise to make payment with respect to such item or service (or any portion thereof under a primary plan (and may, in accordance with paragraph (3(a collect double damages against that entity, or against any other entity (including any physician or provider that has received payment from that entity with respect to the item or service, and they join or intervene in any action related to the events which gave rise to the need for the item or service...
13 (iii...there is established a private cause of action for damages (which shall be in an amount double the amount otherwise provided in the case of a primary plan which fails to provide for primary payments (or appropriate reimbursement in accordance with such paragraphs (1 and (2(A. Clearly, the Social Security Act 1862 (b(1 prohibits Medicare from paying for medical services which have been made or can reasonably be expected to be made promptly under a workers compensation law or plan. It is clear and undisputed that the Federal Government does not want to pay for any medical treatment which is the responsibility of a workers compensation employer or carrier. 5 As with any rule, exceptions and ambiguities exist. One should consider Medicare in two procedural postures. If a workers compensation claimant is also currently eligible for Medicare benefits, one should be mindful of Medicare s prohibition against payment for any medical treatment relating to the work injury. This prohibition on payments has always been a part of the Medicare program. 42 CFR Medicare may make conditional payments for medical services relating to a workers compensation claim in three situations: (1 if the service may not be covered under workers compensation or (2 payment may not be reasonably expected promptly or (3 the employer is contesting the compensability. 42 CFR and 42 CFR In either of the three scenarios, the workers compensation claimant / Medicare beneficiary must cooperate with Medicare if 5 While this law has been in existence for many years, enforcement has certainly increased. Some believe the class-action lawsuit filed as Richard L. Mitchell v. St. Paul Fire and Marine Insurance Company, et al. in Walker County, Alabama on September 5, 2001 increased interest in this area of the law.
14 Medicare takes action to recover any conditional payments. 42 CFR (a. The Centers for Medicare and Medicaid Services (CMS is the governmental unit which acts on behalf of Medicare and enforces Medicare s interests. CMS was previously known as the Health Care Financing Administration (HCFA. Medicare will not make payments for medical treatment which is arguably a workers compensating matter until the claimant has exhausted his or her remedies under the applicable workers compensation law. 42 CFR (b. If the claimant/beneficiary is entitled to a claim for workers compensation benefits and fails to prosecute that claim, Medicare will not pay for services that could have been paid by the workers compensation carrier. If Medicare mistakenly pays for claims which should have been paid by a workers compensation carrier, Medicare has a statutory, super priority right of recovery against the third party payer. 42 U.S.C (y. Third party payers are the carriers or employers but 42 CFR states that Medicare is...subrogated to any individual, provider, supplier, physician, private insurer, state agency, attorney, or any other entity entitled to payment by a third party payer. 42 CFR (g provides Medicare with,...a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, state agency or private insurer that has received a third party payment.. The other posture to consider Medicare is in the context of settlement of the workers compensation claim. The Centers for Medicare and Medicaid Services have put forth the following guideline regarding settlements of workers compensation claims: It is not in Medicare's best interest to review every WC settlement nationwide in order to protect Medicare's interests per 42 CFR (Ref: 7/23/01 Memo Q1(c A WCMSA is not necessary when resolution of the WC claim leaves the medical aspects of the claim open.
15 A WCMSA may be submitted to CMS for review in the following situations: The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR The claimant has a "reasonable expectation"6 of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000. There is no safe harbor for any settlement. It is the position of the Federal Government that all settlements take Medicare s interests into account. If, however, a settlement clearly meets either of the above criteria, a proposed Medicare Set Aside must be sent to CMS, c/o Coordination of 6 Settlements Greater than $250,000 where the Claimant is "Reasonably Expected to Become a Medicare Beneficiary" (Ref: 4/21/03 Memo Q2 An individual has a "reasonable expectation" of Medicare enrollment if any of the following situations apply: (a The individual has applied for Social Security Disability Benefits; (b The individual has been denied Social Security Disability Benefits but anticipates appealing that decision; (c The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits; (d The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months; or (e The individual has an End Stage Renal Disease (ESRD condition but does not yet qualify for Medicare based upon ESRD. To the extent a WC settlement meets both of the criteria (i.e., the settlement is greater than $250,000 AND the claimant is reasonably expected to become a Medicare beneficiary within 30 months of the settlement date, then a CMS-approved Medicare set-aside arrangement is appropriate
16 Benefits Contractor, P.O. Box 33849, Detroit, Michigan, The list of information and documents required is available at C. Cost of Living Adjustments Virginia Code provides for a cost of living adjustment in workers compensation payments for total incapacity and the dependents of a deceased claimant. This section states, in part: A. In the event that the combined disability benefit entitlement of a claimant or his dependents under this title and the Federal Old-Age Survivors and Disability Insurance Act is less then eighty percent of the average monthly earnings of the claimant before disability or death, cost of living supplements shall be payable, in addition to the other benefits payable under this title, in accordance with the provisions of this section to those recipients of awards resulting from occupational disease, accident, or death occurring on or after July 1, For purposes of determining the monthly amount of combined disability entitlements received by a claimant, the claimant may deduct any monthly amounts paid for Medicare... Virginia Code It is necessary for the claimant to establish is entitlement to a cost of living adjustment. If the claimant is not receiving any social security benefits, the claimant should ask the local social security office to produce Form SSA which indicates that they are not receiving social security disability benefits. The Virginia Workers Compensation Commission website offers a free calculation software program at as well D. Releases With increasing frequency, employers have demanded that a claimant sign a Release of all claims as part of any settlement. The Virginia Workers Compensation Commission has set forth the following rule regarding Releases: Blanket Release. The Commission applies a high standard of scrutiny to all settlement proposals which contain blanket release language. The Commission believes that the best interest of the claimant is served when the parties identify the specific date, dates or time period when the alleged
17 accident or accidents are claimed to have occurred. The Commission discourages the use of a general release of all claims. If the settlement contains a blanket release which purports to release the defendants from claims other than a specific work accident or occupation disease, then the parties must provide an additional statement signed by the claimant (and attorney if represented addressing the following issues: (1 The additional consideration given for the blanket release; (2 That the parties have thoughtfully contemplated the reason for the release, and setting forth the specific reasons why such a release is being given; (3 That the claimant understands that the settlement releases the defendants not only from the accident or occupation disease at issue, but for all other accidents or occupational diseases sustained by the employee while in the course of the employment before the date of settlement, including other active pending or potential claims, including all other outstanding awards; (4 Whether the claimant knows of any other active, pending, or potential accident or occupational disease claims; and the specifics thereof; (5 Whether the employment has exposed the employee to risks of occupational diseases, such as working in an environment containing asbestos, coal or rock dust, dangerous chemicals, or loud noise. The Commission strictly enforces these requirements and failure to follow them will certainly result in rejection of the settlement until these rules are followed.
18 EXHIBIT VIRGINIA: IN THE WORKERS' COMPENSATION COMMISSION LISA, Employee, v. VWC File No. VIRGINIA., Employer, and INSURANCE SOCIETY, INC., Insurer. PETITION This case is before the Commission upon Petition of the parties seeking approval of a settlement whereby the claimant, Lisa, receives (1 a lump sum payment of fifty thousand and 00/100 dollars ($50,000; (2 future periodic payments of $ per month for 60 months to commence the first month after the settlement is approved; and (3 payment of all medical expenses incurred through the date of the Order approving settlement which are reasonable, necessary, and causally related to the accident which occurred on October 15, 1997, less approved attorney's fee, and upon payment to her, the defendants are full and finally released from any and all liability to the claimant. The settlement provides as follows: (1 The defendants shall pay to the claimant, less approved attorney's fee, in one lump sum $50,000 plus monthly payments of $ per month for 60
19 months; (2 A lump sum of five thousand and 00/100 ($8, will be placed by claimant in a self-administered account, interest-bearing, to be used for primary or secondary payment of medical services related to the injuries sustained on October 15, 1997 by the claimant that are covered by Medicare, with the claimant maintaining accurate records or receipts for each payment. The claimant will only use the money set aside for the benefit of Medicare for Medicare covered medical expenses; (3 The defendant shall be responsible for any unpaid, authorized, reasonable and necessary medical expenses related to the claimant's occupational injury of October 15, 1997, incurred by the claimant up to, through and including the date of entry of the Order approving this settlement; and (4 The claimant shall be responsible for all other medical expenses. Said settlement as set forth above shall be a complete extinguishment and complete payment of any and all claims of whatsoever kind or nature which the claimant, and all person claiming through the claimant, might have against the defendants, including, but not limited to, claims for past, present, and future temporary total disability benefits (including cost of living adjustments, permanent partial disability benefits, temporary partial disability benefits, permanent total disability benefits, vocational rehabilitation and/or medical expenses under the Workers' Compensation laws of the Commonwealth of Virginia, as a result of the injury allegedly sustained by the claimant on or about October 15, 1997, including any compensable consequence, change-in-condition, aggravation or exacerbation thereof: The petitioners represent of the Commission that the agreed settlement is based upon the
20 following facts: (a Claimant sustained an injury by accident on or about October 15, 1997, while she was employed by the employer at an average weekly wage of $ $497.16; (b The following sums have been paid to, or on behalf of the claimant as of December 31, 2003: (i Indemnity benefits: $ 188, (ii Medical benefits: $ 107, (c The claimant has received medical treatment from her physicians Steven, M.D., Paul, D.O., and Edward, M.D. (d The claimant was determined to have reached maximum medical improvement as indicated in the report of Steven, M.D., dated October 3, 2000, a copy of which is attached hereto; (e (f Claimant is no longer working for the employer; Recognizing the uncertainties of litigation, the parties desire to compromise this matter; (g It further is the desire of the claimant to manage her own affairs and exercise her own options without interference; (h The claimant and the defendants wish to compromise claimant's claim as provided by law as set forth above, which settlement shall be a complete extinguishment of all of claimant's rights against the defendants under the Workers' Compensation laws of Virginia on account of the injury sustained; (i The parties recognize that the Social Security Act provides for the apportionment of workers' compensation benefits received in the form of a lump sum settlement in
MEDICARE AND MEDICAID AVOIDING POST-JUDGMENT AND POST-SETTLEMENT LITIGATION WORKERS COMPENSATION AND MEDICARE SET ASIDE ISSUES INTRODUCTION Over the last 10 years workers compensation practitioners have
Subpart B Insurance Coverage That Limits Medicare Payment: General Provisions 411.20 Basis and scope. (a) Statutory basis. (1) Section 1862(b)(2)(A)(i) of the Act precludes Medicare payment for services
.25 Schedule of [Attorneys'] Attorney's Fees. A. The Commission shall approve [attorneys'] attorney's fees in accordance with the schedule of fees established from time to time by the Commission and set
Policy and Procedures for Recoupment & Coordination of Benefits: Workers Compensation Payment Effective Date: September 1, 2013 Effective Date for Section 32 Agreements: October 1, 2013 Revised: December
SPECIAL TOPICS IN GUARDIANSHIP COMPROMISING CLAIMS FOR MINORS AND INCAPACITATED ADULTS November 8, 2013 Stephanie F. Brown McMickle, Kurey & Branch 200 South Main Street Alpharetta, GA 30009 (678) 824-7800
MONTANA SELF INSURERS ASSOCIATION Executive Director Bob Worthington Board of Directors Rick Clark Plum Creek Timber Co Tim Fitzpatrick MT Schools Group Donna Haeder NorthWestern Corp Marv Jordan MT Contractors
July 23, 2001 To: From: SUBJECT: All Associate Regional Administrators Attention: Division of Medicare Deputy Director Purchasing Policy Group Center for Medicare Management Workers Compensation: Commutation
No Medicare Payments for a Claimant's Work-Related Injury or Disease until the WCMSA has been Exhausted (Ref: 7/23/01 Memo) The purpose of a Workers' Compensation Medicare Set-aside Arrangement (WCMSA)
Medicare Dilemma ADMINISTRATION AND SETTLEMENT OF WORKERS COMPENSATION CLAIMS AND THE MEDICARE DILEMMA I. Introduction Craig B. Nichols 2009 Hansen Dordell 3900 Northwoods Drive, Suite 250 St. Paul, MN
Stipulated Settlements Topics to Consider David Kay Settlement Division Director, State Board of Worker s Compensation Atlanta, Georgia. 1 Topics to Consider when Drafting a Stipulated Settlement Stipulated
LIEN ON ME A Guide to Complying with Medicare s Secondary Payor Act and Pennsylvania s Act 44 April, 2009 HARRISBURG OFFICE P.O. Box 932 Harrisburg, PA 17106-0932 717-975-8114 PITTSBURGH OFFICE 525 William
LONG TERM DISABILITY INSURANCE CERTIFICATE BOOKLET GROUP INSURANCE FOR MONROE CO COMMUNITY COLLEGE SCHOOL NUMBER 704 TEACHERS The benefits for which you are insured are set forth in the pages of this booklet.
NEGOTIATING WITH MEDICARE AND MEDICAID I. MEDICARE PROVIDES HEALTHCARE COVERAGE A. Persons 65 Years Old and Older B. Certain Disabled Persons under 65 C. Persons with End-Stage Renal Disease II. MEDICARE
CITY COUNTY INSURANCE SERVICES TRUST WORKERS' COMPENSATION COVERAGE AGREEMENT Various provisions of this agreement restrict coverage. Read the entire coverage agreement carefully to determine rights, duties,
FactsforWorkers.com A Legal Information Resource for Workers provided by Hedberg & Boulton, P.C. Iowa Workers Compensation Law Fast Facts An Overview on Work-Related Injuries for Iowa Workers What is Workers
NEW MEXICO SELF-INSURERS' FUND WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY PLAN In return for the payment of the premium and subject to all terms of this Policy, we agree with you as follows. GENERAL
Guide for Injured Workers This is a guide to Oklahoma workers' compensation law and rules. It is based on laws and rules in effect in 2015. Laws and rules can change by acts of the Legislature, rulemaking
Policy and Procedures for Recoupment & Coordination of Benefits: Workers Compensation Payment Effective Date: September 1, 2013 I. Authority A. The James Zadroga 9/11 Health and Compensation Act of 2010
Maryland Workers Compensation Commission Introduction Medicare Secondary Payer Act & Workers Compensation Settlement Process What this is not... This presentation is not a tutorial on how to create and
Glossary of Terms and Acronyms COB/COBC Coordination of Benefits - The Coordination of Benefits Contractor consolidates the activities that support the collection, management, and reporting of other insurance
AVOIDING THE PITFALLS WORKERS' COMPENSATION LAW YOU NEED TO KNOW FOR YOUR PERSONAL INJURY PRACTICE Presented for the Bar Association Of the City of Richmond February 21, 2001 ".., By: Andrew J. Reinhardt,
PUBLIC ENTITY RISK MANAGEMENT AUTHORITY MEMORANDUM OF WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE FOR THE PERIOD JULY 1, 2015 TO JUNE 30, 2016 EFFECTIVE: JULY 1, 2015 PUBLIC ENTITY RISK MANAGEMENT
USING MEDICARE SET-ASIDE ARRANGEMENTS IN THIRD PARTY LIABILITY CASES By: Thomas D. Begley, Jr. This Special Report is brought to you by Begley Law Group. begleylawgroup.com This newsletter is not intended
TITLE 13 CHAPTER 12 PART 3 INSURANCE MOTOR VEHICLE INSURANCE UNINSURED AND UNKNOWN MOTORISTS COVERAGE 18.104.22.168 ISSUING AGENCY: New Mexico Public Regulation Commission Insurance Division. [7/1/97; 22.214.171.124
The Employers Guide to Pennsylvania s Workers Compensation Law Table of Contents About this Guide. 3 The Pennsylvania Workers Compensation Act: An Overview for the Pennsylvania Employer....4 Your Duties
2014 Construction of Statute Definition of Injury (Causation) Revises Section 50-6-116, Construction of Chapter, to indicate that for dates of injury on or after July 1, 2014, the chapter should no longer
MEDICARE AND LIABILITY CASES I. The Significant Statutory and Code Provisions A. The Medicare Secondary Payer Statute The Medicare Secondary Payer statute (MSP) has been the law for well over 25 years.
L o n g Te r m D i s a b i l i t y I n s u r a n c e O p t i o n s Long Term Disability Insurance Group Insurance for School Employees INTRODUCTION This booklet will help you understand MESSA's Optional
Long Term Disability Insurance Group Insurance for School Employees FERRIS STATE UNIVERSITY INSTRUCTOR,FACULTY,LIBRARIAN Underwritten by Connecticut General Life Insurance Company 1475 Kendale Boulevard
Set-Aside Arrangements A Combined Effort by Overview: When is Medicare an issue? What is required when Medicare is an issue? Dealing with CMS and Medicare. Problems associated with Medicare in the context
Nebraska Workers Compensation Court Information Sheet: Rights & Obligations under the Nebraska Workers Compensation Law NEBRASKA WORKERS COMPENSATION COURT OFFICIAL SEAL What is workers compensation? Workers
LONG TERM DISABILITY INSURANCE CERTIFICATE BOOKLET GROUP INSURANCE FOR SOUTH LYON COMMUNITY SCHOOL NUMBER 143 TEACHERS The benefits for which you are insured are set forth in the pages of this booklet.
LONG TERM DISABILITY INSURANCE CERTIFICATE BOOKLET GROUP INSURANCE FOR WAYNE WESTLAND COMMUNITY SCHOOLS SCHOOL NUMBER 944 TEACHERS The benefits for which you are insured are set forth in the pages of this
No. 11-1197 ================================================================ In The Supreme Court of the United States --------------------------------- --------------------------------- VERNON HADDEN,
WORKER S COMPENSATION OR NOT-THAT S THE QUESTION. Attorney Reed Noble has successfully handled Workers Compensation cases for clients since 1982. The North Carolina Worker's Compensation Act is designed
A GUIDE TO WORKERS COMPENSATION IN NEW YORK If you live or work in New York State and suffer a work-related injury, illness or disability, you may be eligible for workers' compensation benefits. This summary
CMS Review Thresholds CMS Referral Request A workers compensation settlement may qualify for referral to The Centers for Medicare & Medicaid Services (CMS) under the following review threshold criteria.
MEDICARE AND WORKERS= COMPENSATION CLAIMS WHO=S ON FIRST? Michael E. Rusin January, 2002 Michael E. Rusin Rusin Maciorowski & Friedman, Ltd. 10 South Riverside Plaza, Suite 1530 Chicago, IL 60606 (312)
Instructions for Completing the Represented Settlement Agreement Please read all pages This form is fillable. That means you can type the information onto the form from your computer and print the form.
BEST PRACTICES STIPULATED SETTLEMENTS Pursuant to O.C.G.A. 34-9-15, the State Board of Workers Compensation is authorized to approve Stipulated Settlements. The parties to a claim may enter into a lump
Presented by Bradford & Barthel, LLP Sherri M. Dozier, Director of Client Development and Relations Large Loss Department Specialist Approximately 12.4% of Gross Wages (F.I.C.A) pay for Social Security.
A.B. ASSEMBLY BILL NO. COMMITTEE ON COMMERCE AND LABOR MARCH, 0 Referred to Committee on Commerce and Labor SUMMARY Revises provisions governing workers compensation. (BDR -) FISCAL NOTE: Effect on Local
FORM - COMPLEX ORDER FOR A STRUCTURED SETTLEMENT At an IAS Part of the Supreme Court of The State of New York, held in and for the County of Bronx, at the Courthouse thereof, located at 851 Grand Concourse,
Case 3:07-cv-01180-TEM Document 56 Filed 04/27/2009 Page 1 of 12 UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA JACKSONVILLE DIVISION JAMES E. TOMLINSON and DARLENE TOMLINSON, his wife, v. Plaintiffs,
Medicare Issues in Workers= Compensation Settlements Bennett L. Pugh Melisa C. George Carr, Allison, Pugh, Howard, Oliver & Sisson 100 Vestavia Parkway, Suite 200 Birmingham, Alabama 35216 telephone: (205)
SOCIAL SECURITY DISABILITY BENEFITS, VETERANS BENEFITS, ERISA, ETC.: HOW OTHER MEDICAL/DISABILITY BENEFITS AFFECT YOUR ABILITY TO SETTLE YOUR WORKERS COMPENSATION CLAIM (FROM THE CLAIMANT S PERSPECTIVE)
WC 00 00 00 A (Ed. 4-92) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PLEASE READ THE POLICY CAREFULLY. QUICK REFERENCE BEGINNING ON PAGE INFORMATION PAGE GENERAL SECTION... 2 A. The Policy...
SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this day of, 2015, by and between: "Claimant" "Defendant" "Insurer" Recitals
Impediments to Settlement W. Bruce Barrickman, Esq. 5775 Glenridge Drive Suite E100 Atlanta, GA 30328 678-222-0248 www.bayadr.com IMPEDIMENTS TO SETTLEMENT W. Bruce Barrickman, Esq. Mediation is a great
Missouri Highways and Transportation Commission Policies Category: Subcategory: Sub-Subcategory: ENTERPRISE RISK MANAGEMENT Liability Insurance Self-Insurance Plan SELF-INSURANCE PLAN GENERAL LIABILITY
S h o r t Te r m D i s a b i l i t y I n s u r a n c e O p t i o n s Short Term Disability Insurance Group Insurance for School Employees INTRODUCTION This booklet will help you understand Messa's Optional
UNIVERSITY OF ROCHESTER LONG-TERM DISABILITY PLAN The Long-Term Disability (LTD) Plan provides a monthly income benefit when an individual is totally disabled for more than six months. The benefit provided
INJURED ON THE JOB? A SUMMARY OF THE RIGHTS AND BENEFITS AVAILABLE TO INJURED WORKERS UNDER ILLINOIS LAW Law Offices ANESI, OZMON, RODIN, NOVAK & KOHEN, LTD 161 NORTH CLARK STREET AT RANDOLPH 21ST FLOOR
INSTRUCTION LETTER Dear Prospective Claimant or Claimant Counsel, The Tronox Incorporated Tort Claims Trust (the Trust ) has been established under Chapter 11 of the Bankruptcy Code to resolve all Tort
IN THE SUPERIOR COURT OF THE STATE OF DELAWARE IN AND FOR COUNTY, Petitioner. C.A. NO.: - PETITION FOR APPROVAL OF SETTLEMENT OF PERSONAL INJURY CLAIM OF MINOR (hereinafter the minor. Petitioner,, respectfully
WORKERS COMPENSATION SETTLEMENT DOCUMENT REQUEST WORKSHEET This worksheet supplies important information necessary for the proper preparation of workers compensation settlement documents including evaluation
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: General Section A. The Policy
Examples STANDARD CAPTION STATE BOARD OF WORKERS COMPENSATION 270 PEACHTREE STREET NW ATLANTA, GEORGIA 30303-1299 Claim No. (employee s social security number) Date of Injury Name Company Insurance/Servicing
On April 18, 2011, Kansas Governor Sam Brownback signed a new law changing the workers compensation system. (H.B. 2134) amends the Workers Compensation Act (KSA Sec. 44-501, et seq.) by changing Sections
STATE OF TEXAS CONTRACT FOR SERVICES COUNTY OF DALLAS THIS CONTRACT is made and entered into by and between the CITY OF DALLAS, a Texas municipal corporation, located in Dallas County, Texas (hereinafter
rightlawyers.com RIGHT Lawyers Right Lawyers has successfully represented numerous clients in the areas of car accidents, work injuries, and slip and falls. The goal of this guide is to provide you answers
MEDICARE SET-ASIDE UPDATE I. Social Security Disability Benefits A. Social Security Disability Income (SSDI) B. Obtained via application to the Social Security Administration C. Informal Hearing process
United States Workers Compensation/Indemnification Overview January 18, 2012 Jill Kirila firstname.lastname@example.org Kevin Hess email@example.com 36 Offices in 17 Countries Workers Compensation
MODULE - 5 Public Liability Insurance Act 1991... 5 PUBLIC LIABILITY INSURANCE ACT 1991, AND WORKMEN COMPENSATION ACT 1923 AND MOTOR VEHICLE ACT 1988 5.0 INTRODUCTION In this chapter we will discuss various
I. HISTORICAL BACKGROUND A. Common Law WORKERS COMPENSATION SUBROGATION AND THIRD PARTY SETTLEMENTS Before the advent of workers compensation statutes, the only protection afforded to victims of work place
Welcome to the West Virginia Workers Compensation Webinars! Workers Compensation Benefits West Virginia OFFICES OF THE INSURANCE COMMISSIONER June 13, 2008 Compensability In order for an injury to be compensable
WORKERS CO MPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY ABCDEFGHIJ In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION
settlement planning guide for plaintiffs If you expect to receive a settlement as the result of a major injury or the death of a loved one, it is normal to feel overwhelmed. You may have questions about
Self-Administration Toolkit for Workers Compensation Medicare Set-Aside Arrangements (WCMSAs) For WCMSAs Approved by the Centers for Medicare & Medicaid Services (CMS) Version 1.1 January 5, 2015 1 Table
Administrative Code Title 23: Medicaid Part 306 Third Party Recovery Table of Contents Title 23: Division of Medicaid... 1 Part 306: Third Party Recovery... 1 Part 306 Chapter 1: Third Party Recovery...
August 14, 2012 Centers for Medicare & Medicaid Services Department of Health and Human Services ATTN: CMS-6047-ANPRM Room 445-G Hubert H. Humphrey Building 200 Independence Ave., SW Washington, DC 20201
Insurance Code section 11580.2 (a) (1) No policy of bodily injury liability insurance covering liability arising out of the ownership, maintenance, or use of any motor vehicle, except for policies that
ATTORNEY FOR APPELLANT Randal M. Klezmer Indianapolis, Indiana ATTORNEYS FOR APPELLEE Steve Carter Attorney General of Indiana Frances H. Barrow Deputy Attorney General Indianapolis, Indiana In the Indiana
INDEPENDENT CONTRACTOR SERVICES AGREEMENT THIS AGREEMENT is entered into as of this day of, 2010, by and between the CITY OF MONTROSE, State of Colorado, a Colorado home rule municipal corporation, whose
No-Fault Automobile Insurance By Margaret C. Jasper, Esq. Prior to the enactment of state no-fault insurance legislation, recovery for personal injuries sustained in an automobile accident were subject
CITY OF CONCORD INSURANCE AND INDEMNIFICATION REQUIREMENTS (The 1 st two pages provide basic insurance requirements information.) Insurance Required: See below Sample in Contract Limits of Coverage: Additional
DEFENSE BASE ACT WORKERS COMPENSATION FOR EMPLOYEES OF U.S. GOVERNMENT CONTRACTORS WORKING OVERSEAS Federal law requires all U.S. government contractors and subcontractors to secure workers compensation
The Journal of the Virginia Trial Lawyers Association, Volume 18, Number 4 23 How-To How to address Workers Compensation issues when settling a personal injury case by Stephen T. Harper Whenever a person
CALIFORNIA FALSE CLAIMS ACT GOVERNMENT CODE SECTION 12650-12656 12650. (a) This article shall be known and may be cited as the False Claims Act. (b) For purposes of this article: (1) "Claim" includes any
COLORADO REVISED STATUTES Title 13. Courts and Court Procedure Damages Regulation of Actions and Proceedings Article 20. Actions Part 8. Construction Defect Actions for Property Loss and Damage Construction
PRACTICE GUIDELINES MEMORANDUM TO: FROM: Attorneys Practicing Before Me And Other Interested Persons C. Timothy Corcoran, III United States Bankruptcy Judge DATE: January 3, 2000 1 RE: Sample Bankruptcy
VIRGINIA ACTS OF ASSEMBLY -- 2015 SESSION CHAPTER 585 An Act to amend and reenact 38.2-2206 of the Code of Virginia and to amend the Code of Virginia by adding in Article 7 of Chapter 3 of Title 8.01 a
WASHINGTON INSURANCE GUARANTY ASSOCIATION ACT Section 48.32.010. Purpose 48.32.020. Scope 48.32.030. Definitions 48.32.040. Creation of the association-required accounts 48.32.050. Board of directors 48.32.060.
FOR PUBLICATION ATTORNEY FOR APPELLANT: RANDAL M. KLEZMER Klezmer Maudlin, P.C. Indianapolis, Indiana ATTORNEYS FOR APPELLEE: GREGORY F. ZOELLER Attorney General of Indiana FRANCES BARROW Deputy Attorney